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NEW ORLEANS 

MEDICAL AND SURGICAL 

JOURNAL 

Volume Eighty-One 


JULY, 1928 
TO 

JUNE, 1929 

(Inclusive) 



724-726 Perdido Street 


] 




INDEX TO VOLUME EIGHTY-ONE 


July, 1928 — June, 1929 


— A— 

Abdomen, the acute, by Dr. J. M. Acker, Jr 888 

Abdomen, lower, acute conditions in the female, by Dr W. W. Chipman 463 

Abdominal Surgery — Personal experiences in emergencies, by Dr. Isidore Cohn 551 

Abscesses, lung, treatment, by Dr. S. H. Hairston 634 

Abscess — Subphrenic, by Dr. Alton Ochsner 102 

Accidents — Automobile, mortality in — Editorial 511 

Acker, J. M., Jr. — The acute abdomen - 888 

Acne — Treatment of, by Dr. T. A. Maxwell 120 

Actinomycosis in Louisiana, by Dr. Herman B. Gessner 469 

Adenitis, tuberculous, inguinal glands, by Dr. Edward McCormac 15 

Admiral Grayson heads Gorgas Memoral (Abstract) 572 

Ainhum — A case of, by Dr. R. C. Hill 509 

Alcohol and human life (Abstract) 371 

Allen, Carroll W., — The diseased gall bladder 548 

Alsobrook, H. B., — Interstitial pregnancy unruptured; with report of cases 120 

Anderson, Gilbert C., — Neurology and the ear 504 

Anderson, W. H., — The new era in general surgery 769 

Anesthesia, and damaged heart — Editorial 357 

Anesthesia, spinal, by Dr. J. K. Avent 284 

Anesthesia, ethylene, oxygen, place in general surgery, by Dr. James Thomas Nix 533 

Anesthetist and surgeon, relation to their patient, by Dr. Isidore Cohn 867 

Anomolous kidneys, symptoms, report of three cases, by Dr. Barron Johns 821 

Antigens, and precipitation tests, by Dr. H. W. Butler 742 

Anti-malaria medication — Editorial 835 

Appendicitis, chronic — Editorial 588 

Appendicitis in children, by Dr. Charles James Bloom 377 

Appendicitis, gangrenous, occurring with scarlet fever, by Dr. J. M. Bodenheimer and Dr. 

T. J. Fleming 128 

Armstrong, J. F., — Conservatism in surgery 471 

Arnold, H. L., — Early treatment of strabismus 912 

Arrington, 0. N., — Medical sociology 861 

Arthritis, by Dr. John T. O’Ferrall 809 

Arthritis, infectious — 0-lodoxybenzoic acid in treatment of (Abstract) 48 

Arthritis, surgical treatment, by Dr. John T. O’Ferrall 899 

Atrophy, progressive neural muscular (peroneal type) — Case Report, by Dr. W. J. Cavanaugh 

and Dr. Hyman Tucker 290 

Avent, J. K., — Spinal anesthesia 284 

— B— 

Bacteremia, complicating acute otitis media, by Dr. D. C. Montgomery 907 

Balfour, Marshall C., — Training health workers 694 

Banti’s disease, followed by splenectomy, (case report), by Dr. H. E. Guerriero 137 

Bass, Elizabeth, — A consideration of some of the intestinal parasites with a report of three 

cases of “oxyuris incognita” infestation 342 

Bayon, Henry, — The association of quinidin sulphate and digitalis in auricular fibrillation.... 22 

Bell, M. H., — Contusions of the eye 798 

Benedict, William L., — Foreign proteins in the treatment of diseases of the eye, by Dr. Wil- 
liam L. Benedict and Dr. Charles W. Rucker 782 

Beriberi in Louisiana (Abstract) Ill 

Bessesen, Alfred N., — Medical therapy in gall-bladder disease 205 

Bethea, — Dr. Oscar W. Bethea honored 300 

Bethea, Oscar W., — Blood pressure in pulmonary tuberculosis 314 

Biliary system, surgical diseases of, by Dr. Earl Garside 576 

Blastomycosis, by Dr. Aldo Castellani 260 

Blood pressure in pulmonary tuberculosis, by Dr.. Oscar W. Bethea 314 

Blood pressure, technic for clinical measurements, by Dr. Clyde Brooks 287 


IV 


Index 


Bloom, Charles James, — Appendicitis in children 377 

Bodenheimer, J. M., — Gangrenous appendicitis occurring simultaneously with scarlet fever 

(Case Report), by Dr. J. M. Bodenheimer and Dr. T. J. Fleming 128 

Bodenheimer, J. M., — Pseudocyesis 632 

Boebinger, M. J., — A plea for the selection of the pars membranacea in puncturing the Max- 
illary sinus 806 

BOOKS REVIEWED. 

Nix — Reflections: a book of poems 83 

Petty — Diabetes: its treatment by insulin and diet 83 

Tylecote and Fletcher — Diagnosis and treatment of diseases of the lungs 84 

Rivirs — Filterable viruses 84 

Rose — Physical diagnosis 84 

Cowdry — ^Special cytology 85 

Sante — Lobar pneumonia: a roentgenological study 85 

Hare — The use of symptoms in the diagnosis of disease 85 

Ross — Post-mortem appearances 85 

De Lee — The principles and practice of obstetrics 86 

Shastid — An outline history of ophthalmology 87 

Mumford — Healthy growth 87 

Montague — Troubles we don’t talk about 87 

Woldenberg — The prevention of preventable orthopedic defects 87 

Annals of the Pickett — Thomson Research Laboratory, volume II 87 

Foster — The examination of patients 88 

Ophthalmic year book 88 

Jordan — A text-book of general bacteriology 88 

Graves — Gynecology 154 

Bacon and Saunders — A manual of otology 155 

Berry — Brain and mind or the nervous system of man 155 

Wilkinson — Strabismus: its etiology and treatment , 155 

Rehfuss — The diagnosis and treatment of diseases of the stomach 156 

Burgess — Nurses, patients and pocketbooks: report of a study of the economics of nursing 

conducted by the committee on the grading of nursery schools 157 

Ellis — Studies in the psychology of sex 158 

Pardee — Clinical aspects of the electrocardiogram 158 

Thom — Mental health of the child 158 

Chopra and Chandler — Anthelmintics and their uses 158 

Mac Gregor — Mosquito surveys 158 

Rogers — Recent advances in tropical medicine 232 

Taylor — Crawford W. Long 232 

Erleigh — The mind of the growing child 232 

Freud — Technic of child analysis 233 

Webb — Rene Theophile Hyocinthe Laennec 233 

Rohdenburg — ^Clinical laboratory procedures 233 

Mayo Clinic — Collected papers 233 

Papacostas and Gati — Les Association Microbiennes 234 

Bethea — Clinical medicine 234 

Lenormant — Plaies et maladies infectreuses des mains por le Dr. Marc Iselin, Ancien interne 

des Hospitaux 234 

Redway — The springtime of physick 235 

Barker — The young man and medicine 235 

Thomas — Asthma, its diagnosis and treatment 236 

Baby’s health day by day 236 

Stewart — Compend of pharmacy 236 

Sheehan — Plastic surgery of the orbit 304 

Pende — Constitutional inadequacies: an introduction to the study of abnormal conditions 305 

Strecker and Ebaugh — Practical clinical psychiatry for students and practitioners 305 

International Clinics (Vol. II.) 306 

Pelouze — Gonococcal urethritis in the male 306 

International clinics (Vol. III.) 307 


Index 


V 


Clendenning and others — Modern methods of -treatment 307 

Hamilton — Introduction to objective psychopathology 307 

Roth — Cardiac arrythmias 307 

International Clinics (Vol. I.) 307 

Balyeat — Hay fever and asthma 308 

Ford — Textbook of bacteriology 308 

Alvarez, — Mechanics of the digestive tract 374 

Criteria for the classification and dignosis of heart disease — Heart Committee of New York 

Tuberculosis and Health Association 374 

Wilson, — A laboratory manual of physiological chemistry 874 

Carter, — Bacteriology for nurses 374 

Wyard, — A handbook of the diseases of the stomach 375 

Kanner, — Folklore of the teeth 875 

Wright, — Muscle function 375 

Reid, — Heart in modem practice 375 

Barnhill, — The nose, throat and ear 376 

Gradwohl, — Blood and urine chemistry 376 

John, — Diabetic manual for patients 876 

Moynihan, — Addresses on surgical subjects 454 

Giltner, — Elementary text-book of general microbiology 454 

Scott, — Hughes, practice of medicine 454 

Cemach, — Surgical diagnosis in tabular outline for students and physicians 454 

Clark, — The determination of hydrogen ions 454 

Terry and Pellens, — The opium problem 455 

International Medical Annual 455 

Juilly, — Practical surgtery of the abdomen 455 

La Vake, — Handbook of clinical gynecology and obstetrics 456 

International clinics 456 

Fitch, — Medical formulary 456 

Pearson and Wyllie, — Recent advances in diseases of children 456 

Audle, — Calcium therapy 456 

Speed, — Textbook of fractures and dislocations 524 

Joslin, — The treatment of diabetes mellitus 525 

Gould, — Pocket medical dictionary 525 

Hozen, — Syphilis 525 

Osier, — Modern medicine 525 

Osier, — Modern medicine, its theory and practice 525 

Phillips, — Diseases of ear, nose and throat 525 

Hall, — Ultra-violet rays in the treatment and cure of disease ; 526 

Lovatt, — Recent advances in physiology 526 

Stedman, — Stedman’s medical dictionary 600 

Eddy, — Nutrition 600 

Long, — History of pathology 600 

Bram, — Goiter prevention and thyroid protection 600 

Lorand, — The ultra-violet rays 678 

Blum, — Practical dietetics in health and disease 678 

Cramer, — Fever, heat regulation, climate, and the thyroid-adrenal apparatus 678 

Crowe, — Bacteriology and surgery of chronic arthritis and rheumatism 679 

Diseases of the intestines: including the liver, gall-bladder, pancreas and lower alimentary 

tract 679 

Park, — Public health and hygiene 679 

Wheeler and Hunter, — Laboratory manual of the Massachusetts General Hospital 680 

Emerson, — Physician and patient : 680 

Tilney, — The brain from ape to man 680 

Physical education activities for high school girls 680 

Peter, — Extra-ocular muscles 765 

Coffey, Brown, and Humber, — Angina pectoris 765 

Kaye, — Roentgenology: its early history, some basic physical principles and the protective 

measures 766 


VI 


Index 


Schamberg, — A compend of diseases of the skin ^66 

Lawrence,— The diabetic life: its control by diet and insulin. A concise practical manual 

for practitioners and patients Y66 

Ogilvie, — Recent advances in surgery 

Kahn, — The Kahn test 

Dennie, — Syphilis Ygg 

Bowen, — Medical department of the United States Army in the World War 766 

Monrad-Krohn, — Clinical examination of the nervous system 767 

Rowe, — A handbook for the diabetic rjgrj 

FoAvweather, — A handbook of clinical chemical pathology 757 

Goldzieher, Max A., — The adrenals 7g7 

National Health Series 7gg 

Weaver, and others, — Practical Medicine Series.. 7gg 

Kendall, — Bacteriology, general, pathological, and intestinal 349 

Waring, — Surgical treatment of malignant disease 349 

McClung, — Handbook of microscopical technique.. g4g 

Rutherford, — Diseases of the eye ggg 

Marriott, — Recent advances in chemistry in relation to medical practice 35O 

McKittrick- and Root, — Diabetic surgery ggg 

Chapin and Royster, — Diseases of children gg,2 

Chesser, — Child health and character gg2 

Yeomans, — Proctology ggg 

Chandler and Wood, — Lipiodol in the diagnosis of thoracic disease 947 

Stitt, — The diagnosis and treatment of tropical diseases 947 

Lambourne and Mitchell, — Qualitative and volumetric analysis for medical students 947 

Evans, — Spinal anesthesia 347 

Rice, — Racial hygiene g4g 

Burns, — Methods of biological assay 94g 

Graham, — Year book of general surgery 94g 

Lord, — Pneumonia 94g 

Armengol, — Contribution to the study of heredity in tuberculosis 943 

Armengol, — On the variability in the reactions of the specific products of tuberculosis 948 

Velez, — The polymorphism of the tuberculous virus 94g 

Lopez, — Short course on the surgical tuberculoses 94g 

Armengol, — Contribution to the experimental study of nuclear inversion (the Velez sign) 

in tuberculosis 948 943 

Bass and Johns — Practical clinical laboratory diagnosis 949 

Connor, — Surgery in the tropics 949 

Brain and Strauss, — Recent advances in nurology 949 

Young and Waters, — Urological roentgenology 959 

Jerman, — Modern X-ray technic 95O 

Rolleston, — Aspects of age, life and diseases 95O 

Leriche and Policaid, — The normal and pathological physiology of bone 95I 

Brooks, — Angina pectoris 954 

Ibotson, — Partnershps, combinations, and antagonisms in disease 954 

Forrester, — Imperative traumatic surgery 954 

Mellish-Wilson, — The writing of medical papers 954 

Miller, — An outline of gynecology for students 952 

Kaufman, — Pathology for students and practitioners 952 

— B— 

Bordeaux, T. D., — Tuberculosis 324 

Brewster, C. B. — (joint author), see Lyons, Shirley C 493 

Brewster, Hyder F., — (joint author). See Jamison, Chaille 354 

Brooks, Clyde, — Technic for clinical blood pressure measurements 287 

Brucella metitensis var. abortus infection in man. — Editorial 294 

Bumpus, Herman C., — Genital tuberculosis, by Dr. Herman C. Bumpus and Dr. Gersham J. 

Thompson 681 

Burns — treatment of, by Dr. R. A. Cutting 442 

Butler, H. W., — Comparative results with the Wassermann and precipitation tests 317 

Butler, H. W., — Antigens and the precipitation test 742 

Butler slide test, by Dr. B. G. Efron and Dr. C. A. Weiss 343 


Index vii 

— C— 

Cancer — cervix — radium in, by Dr. Joseph Cohen - 401 

Cancer — diagnosis of early uterine (Abstract) 

Cancer — now second as cause of death (Abstract) 523 

Cancer — prophylaxis — special reference to cervix uteri, by Dr. C. Jeff Miller 253 

Cancer — the complications of, by Dr. George T. Pack 180 

Capital investment in medicine — Editorial 590 

Carcinoma — stomach — two stages operation for (Abstract) 220 

Cardiac asthma — Editorial 

Cardiology — Some principles and practices in, byDr. George R. Herrmann 43G 

Cardiorrhaphy — case of ventricular puncture, by Dr. J. Q. Graves 914 

Cardiovascular diseases — value and limitations of laboratory methods in clinical investiga- 

of, by Dr. C. J. Wiggers 601 

Case Reports and Clinical iSugg’estions 136, 209, 290, 354, 509 

Cassegrain, Octave Charles, — Extensive osteomyelitis with massive resection 326 

Castellani, Aldo, — Blastomycosis 260 

Castellani, Aldo — Tropical dermatomycoses in New Orleans and Louisiana 49 

Cavanaugh, W. J. — Progressive neural muscular atrophy (peroneal type) — Case Report — 

by Dr. W. J. Cavanaugh and Dr. Hyman Tucker 290 

Celiac disease — diagnosis and treatment — report of two cases, by Dr. C. T. Williams 647 

Champenois, Fern, — The eye picture in relation to intracranial lesion, with report of case.... 795 

Chancre — extra-genital — of the umbilicus, by Dr. M. Wolf 211 

Charity Hospital Medical Staff transactions 70, 444, 512, 591, 666, 836, 931 

Charity Hospital Surgical Staff transactions 146, 444, 513, 666, 757, 839, 932 

Chiropractic — present status in Louisiana — Editorial 663 

Child-Labor — world standards (Abstract) 12 

Child — the sugar-fed, by Dr. Seale Harris 159 

Child Welfare extension service — Editorial 756 

Chipman, W. W., — Acute conditions in the lower abdomen of the female 463 

Cholecystography — simultaneous with determination of hepatic function (Abstract) 226 

Cleft palate — when and how treated, by Dr. E. D. Fenner 718 

Cohen, Joseph, — Radium in cancer of the cervix. General remarks, with report of cases 401 

Cohn, Isidore, — Personal experiences in abdominal surgery emergencies 551 

Cohn, Isidore, — The relation of the surgeon and the anesthetist to their patient 867 

Cohn, Isidore, — Surgery of the reticulo-endothelial system (Review) 128 

Colon — common disorders — observed in treatment of chronic invalid, by Dr. E. L. Eggleston.... 686 

Come to New Orleans — Editorial 755 

Comparable results with the Wassermann and precipitation tests (announcements) 300 

Contract Practice — Editorial 928 

CORRESPONDENCE FROM 

Dr. Rudolph Matas 73 

Dr. G. Farrar Patton 293 

A. M. Vickery 370 

Dr. F. M. Johns 440 

Dr. W. C. Rappleye 450 

Dr. Weller Van Hook 674 

Dr. F. F. Young 674 

Mrs. Oscar Dowling 941 

Dr. F. M. Thornhill 941 

Crawford, Walter W., — Radium in the treatment of uterine diseases 474 

Crisler, J. Augustus, — Yesterday and today in medicine 1 ... 89 

Cummins, Harold, — The use of foot-prints and finger-prints as identity records in the mater- 
nity 493 

Cutting, R. A., — The treatment of burns 112 

Cystadenoma — papillary — of the breast, report ofa case, by Dr. R. C. Hill 209 

— D— 

Daly, 0. P., — Uterine hemorrhages and their significance 624 

Danna, J. A., — Treatment of pleural effusion, including empyema, by evacuation and air re- 
placement, with consideration of twelve cases of empyema so treated 713 


Index 


viii 

Barrington, John, — The doctor and the public 309 

Davis, Carl Henry, — The obstetrical patient 921 

Dental health program — some essentials in, by Dr. W. R. Wright 703 

Dermatomycoses — tropical — in New Orleans and Louisiana, by Dr. Aldo Castellani 49 

Diet — an important factor in health and disease, by Dr. Allan Eustis 278 

Digitalis — by Dr. T. E. Williams 813 

Dimitry, T. J., — Myopia is essentially a pathological condition 432 

Diphtheria, by Dr. R. T. Lucas 414 

Doctor — and the public, by Dr. John Barrington 309 

Donald, D. C., — The gall-bladder. Its pathological changes and surgical treatment 38 

Duncan, A. K., — Ptosis support for the very thin individual 423 

Durel, Walace J., — The clinical value of the neutrophile nucleus index, the lymphocyte in- 
dex, and the monocyte index in tuberculosis 480 

Dwight — Frost cardio — respiratory test — results with diagnosis of myocardial insufficiency, 

by Dr. Allan Eustis 605 

— E— 

Ear — and neurology, by Dr. Gilbert C. Anderson 504 

Economics — medical — some problems in, by Dr. W. H. Frizell 853 

Efron, B. G., — The Butler slide test, by Dr. B. G. Efron and Dr. C. A. Weiss 318 

Eggleston, E. L.,— Common disorders of the colon observed in the treatment of the chronic 

invalid 686 

Endemic typhus fever in the United States (Abstract) 591 

Endocrine — influence on gastric secretion — special reference to hypothyroidism, by Dr. M. D. 

Levy 487 

Epidemic — rise and fall — Editorial 664 

Ergosterol — irradiated — clinical experience with (Abstract) 284 

Ethics — medical, by Dr. F. M. Thornhill 855 

Ethylene — oxygen anesthesia — place in general surgery, by Dr. James Thomas Nix 533 

Etiquette — professional (Abstract) 930 

Eustis, Allan, — Diet — an important factor in health and disease 278 

Eustis, Allan, — The diagnosis of myocardial insufficiency: results with modification of the 

Dwight-Frost cardio-respiratory test 605 

Eye — contusions, by Dr. M. H. Bell 798 

Eye — diseases — foreign proteins in treatment, by Dr. William L. Benedict and Dr. Charles 

Charles W. Rucker 782 

Eye picture — relation to intracranial lesions; report of case, by Dr. Fern Champenois 795 

— F— 

Fenner, E. D., — Cleft palate; when and how it should it be treated 718 

Fever — endemic typhus in the United States (Abstract) 591 

Fever — glandular, report of a small epidemic, by Dr. I. I. Lemann 187 

Fleming, T. J. — (joint author) see Bodenheimer, J. M. 128 

Flood — Mississippi, and health work (Abstract) 67 

Food contamination, by Dr. D. G. Rafferty 775 

Foot-prints and finger-prints— use as identity records in the maternity, by Dr. Harold Cum- 
mins 493 

Fortier, Lucien — Radiation in sarcomata, by Dr. Lucien Fortier and Dr. T. T. Gately 412 

Fossier, A. E., — The early history of the New Orleans Parish Medical Society 3 

Frank, L. iS., — Standard milk ordinance 871 

French, E. B., — The better physician 773 

French Hospital Medical Staff meetings 513, 758 

Frizell, W. H., — Some problems in medical economics 853 

Fuchs, Val H.,— Nasal fractures and their treatments 802 

Fungus — infections of the hands and feet, by Dr. Foster M. Johns 527 

— G— 

Gall-bladder disease — medical therapy, by Dr. Alfred N. Bessesen 205 

Gall-bladder — pathological changes — surgical treatment, by Dr. R. C. Donald 38 

Gall-bladder — the diseased, by Dr. Carroll W. Allen 548 

Gamble, H. A., — Acute osteomyelitis 893 


Index 


IX 


Garrison, Harvey F., — The control of tuberculosis in infants and children 96 

Garside, Earl, — Surgical diseases of the biliary system 576 

Gas-heating — defective appliances — serious health hazard (Abstract) 446 

Gately, T. T., — (joint author), — see Fortier, Lucien 412 

Genital tuberculosis, by Dr. Hermon C. Bumpus and Dr. Gersham . J. Thompson 681 

Gessner, Herman B., — Actinomycosis in Louisiana 469 

Gondolf, H. J., — A bacteriological study of the Gram negative bacilli found in fifty cases 

of infection of the urinary tract, by Dr. H. J. Gondolf and Dr. M. S. Stringer 735 

Gonorrhea, modern treatment, by Dr. H. W. E. Walther 199 

Gram negative bacilli, study of fifty cases urinary infection, by Dr. H. J. Gondolf and Dr. 

M. S. Stringer 735 

Graves, J. Q., — Cardiorrhaphy with report of case of ventricular puncture 914 

Guerriero, H. E., — A case of advanced Banti’s disease followed by splenectomy 137 

— H— 

Hairston, S. H., — Treatment of lung abscesses 634 

Harris, Seale, — The sugar-fed child 159 

Hay fever and asthma, treatment, by Dr. William Scheppegrell and Dr. N. F. Thiberge 337 

Health audits (Abstract) 330 

Health program, full time, in Mississippi following flood, by Dr. J. G. Townsend 245 

Health, through advertising (Abstract) 138 

Health work, and Mississippi flood (Abstract) 67 

Health work, progress in Mississippi flood area (Abstract) 477 

Health workers training, by Dr. Marshall C. Balfour 694 

Heart borders, percussion of — Editorial 213 

Heart disease, comments on treatment (Abstract) 587 

Heineck , Aime Paul, — Traumatic rupture of the normal spleen 636 

Hemorrhages, uterine, their significance, by Dr. 0. P. Daly 624 

Hemorrhoids — report of 1,000 cases treated by office methods, by Dr. J. W. Warren 902 

Henderson, W. F., — (joint author), see Weil, A. L, 426 

Herold, Hon. S. L., — Medical expert testimony 237 

Herrmann, George R., — Some principles and practices in cardiology 436 

Hiccoughs, hysterical, with assocated phenomena, by Dr. Walter J. Otis 731 

Hill, R. C.,— Papillary cystodenoma of the breast, report of a case... 209 

Hill, R. C., — A case of ainhum 509 

Holmes, T. W., — The use of radium in malignancies and certain gynecological conditions 477 

Hospital, fear of is unwarranted (Abstract) 3 

Hosptal service in the United States — Editorial 213 

Hospital Staff Transactions 70, 141, 216, 358, 444, 512, 591, 666 , 757, 837, 931 

Hotel Dieu Staff Proceedings 757 ^ g38 

Hyperchlorhydria, analysis of the history in diagnosis, by Dr. Oscar W. Bethea 573 

— I— 

Infections, coccogenic, by Dr. T. A. Maxwell 575 

Infection, with bacillus of Pfeiffer — Editorial 5 II 

Influenza, prevention — Editorial 539 

Insurance, Group — Editorial 93 O 

Interstate Postgraduate Association — Editorial 215 

Intracronial lesion, the eye picture in relation to, by Dr. Fern Champenois 795 

— J— 

Jamison, Chaille, — Case report of lobar pneumonia, type II, with positive blood culture, by 

Dr. Chaille Jamison and Dr. Hyder F. Brewster 534 

Jamison, Chaille, — Observations of pneumonia 74 O 

Jaundice, in untreated syphilis, by Dr. J. Holmes Smith I 94 

Jaundice, spirochetal (Abstract) 95 

Johns, Barron, — Obscure symptoms presented by anomalous kidneys; report of three cases 821 

Johns, Foster M., — Fungus infections of the hands and feet 527 


X 


Index 


— K— 

Kerlin, D. L., — Some interesting spinal cord lesions 566 

Kerlin, W. S., — Tularemia, review of literature with report of cases 723 

Kidneys, anomalous, symptoms, report of cases, by Dr. Barron Johns 821 

Lawson, E. H., — A consideration of the sedimentation rate of erythrocytes 727 

Legislative matters — Editorial 139 

Lemann, I. I., — Glandular fever with report of a small epidemic in a local orphanage 187 

Leper, national home at Carville (Abstract) 212 

Leprosy, in United States (Abstract) 596 

Leprosy, in United States (Abstract) 665 

Lett, F. M., — The bicornate uterus 918 

Levy, M. D., — Endocrine influence on gastric secretion with special reference to hypothyroid- 
ism 487 

Lewis, Ernest S., — The evolution of medical teaching in New Orleans 1 

Lipiodol, as an aid to diagnosis in nasal sinus conditons, by Dr. A. I. Weil and Dr. W. F. 

Henderson 426 

Liver, effects on blood sugar lerel (Abstract) 946 

Longer life week — Editorial 442 

Louisiana State Medical iSociety, history of — Editorial 140 

Louisiana State Medical Society News 74, 148, 227, 296, 368 449 

516, 593, 671, 760, 841, 937 

Lucas, John Fair, — Placenta praevia 628 

Lucas, R. T., — Diphtheria 414 

Lung, abscesses, treatment, by Dr. S. H. Hairston 634 

Lymphosarcoma, ileum, report of case, by Dr. Martin 0. Miller 322 

Lyons, Shirley C., — The treatment of varicose veins, by injections of sclerosing solutions, by 

Dr. Shirley C. Lyons and Dr. C. B. Brewster 498 

— M— 

Martyrs of medicine (Abstract) 37 

Matas, Rudolph, — Citation of by Princeton Uinversity 73 

Matas, Rudolph, — Correspondence re Golden Anniversary celebration 73 

Maxwell, T. A., — Treatment of acne 126 

Maxwell, T. A., — Coccogenic infections 575 

May, Clarence P., — Constitutional psychopathic inferiority 19 

McCormac, Edward, — A study of tuberculous adenitis confined to the inguinal lymph glands 15 

Measles, prevention and modification by measles antidiplococcus goat serum (Abstract) 166 

Medical economics, some problems in, by Dr. W. H. Frizell 853 

Medical, electrical, pharmaceutical exposition in Mexico (Abstract) 10 

Medical ethics, by Dr. F. M. Thornhill 855 

Medical Society, how to kill a, (Abstract) 448 

Medical Society meetings — Editorial 834 

Medical sociology, by Dr. 0. N. Arrington 861 

Medical teaching, evolution, in New Orleans, by Dr. Ernest S. Lewis 1 

Medicine, a monument to (Abstract) 498 

Mercurochrome, use as vaginal antiseptic in induction of labor (Abstract) 179 

Milk, standard ordinance, by Dr. L. S. Frank 871 

Miller, C. Jeff, — The young physician 93 

Miller, C. Jeff, — The prophylaxis of cancer, with special reference to the cervix uteri 253 

Miller, C. S., — The consideration of the psychic factors in physical disease 611 

Miller, Martin O., — Lymphosarcoma of the ileum with report of a case 322 

Mississippi iState Medical Association News 78, 151, 230, 301, 372, 451 

520, 597, 675, 762, 844, 942 

Montgomery, D. C., — Bacteremia: complicating acute otitis media 907 

Morphin, effect on function of normal and pathologic kidney (Abstract) 326 

Mortality, in automobile accidents — Editorial 511 

Multiplicity of medical meetings — Edittorial 68 

Musser, J. H., — The problems of uremia 174 

Myocordial insufficiency, diagnosis with Dwight-Frost cardio-respiratory test, by Dr. Allan 

Eustis 605 


Index 


XI 


— N— 

Myopia, essentially pathological condition, by Dr. T. J. Dimitry 432 

Nasal fractures, their treatment, by Dr. Val H. Fuchs 802 

National Election — Editorial 356 

National Institute of Health — Editorial 356 

Neurology, and the ear, by Dr. Gilbert C. Anderson 504 

New officers of Louisiana State Medical Society — Editorial 836 

New Orleans Parsh Medical Society, early history, by Dr. A. E. Fossier 3 

New pharmacy (Abstract) : 795 

New President of Louisiana State Medical Society — Editorial 834 

Nine years going begging (Abstract) 252 

Nix, James Thomas, — The place of ethylene-oxygen anesthesia in general surgery 533 

Noguchi honored (Abstract) 519 

— 0 — 

Obstetrical, patient, by Dr. Carl Henry Davis 921 

Ochsner, Alton, sulphrenic abscess 102 

Ochsner, Alton, — The surgical treatment of pulmonary tuberculosis 876 

Ochsner, Alton, — Wounds 746 

Ochsner, Alton, — Wounds (Part II) 826 

O’Ferrall, John T., — Arthritis 809 

O’Ferrall, John T., — Surgical treatment of arthritis 899 

0-Iodoxybenzoic acid, in treatment of infectious arthritis (Abstract) 48 

Orleans Parsh Medical Society 71, 147, 221, 366, 447, 515, 592, 669, 759, 839, 935 

Osteoarthropathy, hypertrophic pulmonary, by Dr. Lester J. Williams 708 

Osteomyelitis, acute, by Dr. H. A. Gamble 893 

Osteomyelitis, extensive, with massive resection, by Dr. Octave Charles Cassegrain 326 

Otis, Walter J., — Hysterical hiccoughs with associated phenomena 731 

Otitis media, acute, bactermia complicating, by Dr. D. C. Montgomery 907 

Out of his line (Abstract) 946 

— P— 

Pack, George T., — The complications of cancer 180 

Parasites, intestinal, consideration, report of three cases of “oxyuris incognita”, by Dr, 

Elizabeth Bass 342 

Parasitologist, new, in Louisiana — Editorial 294 

Paresis, malaria therapy in, by Dr. H. R. Unsworth 167 

Pars membranacea, selection of in puncturing maxillary sinus, by Dr. M. P. Boebinger 806 

Patient pays the piper (Abstract) 367 

Patient pays the piper (cont.) (Abstract) 426 

Patton, G. Farrar, — Personal recollections 10 

Payne, A. G., — Thyrotoxicosis, symptoms and importance of early recognition 564 

Pension applications, worthy. Editorial 664 

Pernicious anemia, Editorial 69 

Personal recollections, by Dr. G. Farrar Patton 10 

Physician and jury duty — Editorial 294 

Physicians in the employment of the United States Government — Editorial 214 

Physician, relation to public, by T. Semmes Walmsley 13 

Physician, the better, by Dr. E. B. French 773 

Physician, the young, by Dr. C. Jeff Miller 93 

Pigford, Russell C., — Reticulo-endothelial system in disease (Review) 59 

Pituitary harmones, isolation of (Abstract) 599 

Placenta praevia, by Dr. John Fair Lucas 628 

Pleural effusion, treatment, etc,, by Dr. J. A. Danna 713 

Pneumonia, lobar type II, case report, by Dr. Chaille Jamison and Dr. Hyder F. Brewster 354 

Pneumonia, observations of, by Dr. Chaille Jamison 7 10 

Polak, John Osborn, — Toxemias of pregnancy 457 

Post-operative treatment, personal impressions, by Dr. J. D. Rives 42 

Precipitation tests, and antigens, by Dr. H. W. Butler 742 

Precipitation tests, comparative results with Wassermann, by Dr. H. W. Butler 317 

Pregnancy, interstitial, unruptured, with report of cases, by Dr. H. B. Alsobrook 120 


Index 


xii 

Pregnancy, toxemias of, by Dr. John Osborne Polak 457 

Presbyterian Hospital Clinical Society meetings 145, 353, 513, 932 

President Fenner — Editorial 5.9O 

President Mississippi State Medical Associaton — Editorial 929 

Promotion of common welfare: aim of modem medicine (Abstract) 665 

Promotion of common welfare: aim of modern medicine (cont.) (Abstract) 756 

Proteins, foreign, in treatment of eye diseases, by Dr. William L. Benedict and Dr. Charles 

W. Rucker 782 

Protozoa, human intestinal, clinical diagnosis of (Abstract) 231 

Pseudocyesis, by Dr. J. M. Bodenheimer 632 

Psychic factors, consideration in physical disease, by Dr. D. C. S. Miller 611 

Psychopathic, constitutional inferiority, by Dr. Clarence P. May 19 

Ptosis, support of thin individual, by Dr. A. K. Duncan 423 

Publications Received 88, 158, 236, 308, 376, 456, 526 

600, 680, 768, 852, 952 

Puerperal infection, cause, prevention and treatment, by Dr. Thomas B. Sellers and Dr. John 

T. Sanders 619 

— Q— 

Quinidin sulphate, digitalis, association in auricular fibrillation, by Dr. Henry Bayon 22 

— R— 

Rabies, two human cases of (Abstract) 514 

Rabies, the public and the profession — Editorial 441 

Radiation, in sarcomata, by Dr. Lucien Fortier and Dr. T. T. Gately 412 

Radiological frauds and improper practices — Editorial 70 

Radium, in cancer of cervix, by Dr. Joseph Cohen 401 

Radium, in treatment of uterine disease, by Dr. Walter W. Crawford 474 

Radium, use of, in malignancies and certain gynecological conditions, by Dr. T. W. Holmes.... 477 

Rafferty, D. G., — Food contamination 775 

Rattlesnake venom, poisoning, mechanical treatment of experimental (Abstract) 220 

Registry for technicans — Editorial 755 

Respiratory disease, importance as cause of disability among industrial workers (Abstract).... 215 

Reticulo-endothelial system in disease (Review), by Dr. Russell C. Pigford 59 

Reticulo, endothelial system, surgery of, by Dr. Isidore Cohn 128 

Reviews 59, 128, 350, 576, 652, 746, 826 

Rives, J. D., — Post-operative treatment. Some personal impressions;. 42 

Roentgen-ray, treatment in malignant bone tumors, by Dr. C. P. Rutledge 406 

Rogers, Jane Grey, an appreciation — Editorial 442 

Rucker, Charles W., — (joint author), see Benedict, William L 782 

Rutledge, C. P., — The roentgen-ray treatment of malignant bone tumors, with report of cases 406 

— S— 

Sanders, John T., — (joint author), see Sellers, Thomas B 619 

Sanders, R. L., — Some principles underlying the surgical management of lesions of the 

stomach 31 

Sarcomata, radiation in, by Dr. Lucien Fortier and Dr. T. T. Gately 412 

Scarlet fever, treatment and prevention by specific antitoxins and serums (Abstract) 772 

Scheppegrell, William, — The treatment of hay fever and asthma, by Dr. William Schep- 

pegrell and Dr. N. F. Thiberge 337 

Science, application to practice of medicine (Abstract) 927 

Sedimentation rate, of erythrocytes, a consideration, by Dr. E. H. Lawson 727 

Sellers, Thomas B., — The case, prevention and treatment of puerperal infection, by Dr. 

Thomas B. Sellers and Dr. John T. Sanders 619 

Semi-centennary celebration — Editorial 68 

Signorelli, John, — The B. C. G. vaccine. Report on certain researches, by Dr. A. Bocchini. 

Abstract translation with introduction 350 

Sinus disease, para-nasal, importance in diagnosis, by Dr. G. M. Street 331 

Smith, J. Holmes, — Jaundice occurring in untreated syphilis 194 

Sociology, medical, by Dr. 0. N. Arrington 861 


Index 


Soniat Mercy Hospital Staff Transactions 70, 

Southen Baptist Hospital Staff Transactions 141, 216, 

Spinal cord, lesions, interesting, by Dr. D. L. Kerlin 

Spleen, traumatic rupture, by Dr. Aime Paul Heineck 

Status Lymphaticus — Editorial 

Strabismus, early treatment, by Dr. H. L. Arnold 

Street, G. M., — The importance of para-nasal sinus disease in general diagnosis 

Stomach, lesions, surgical management, by Dr. R. L. Sanders 

Stringer, M. S., — (joint author), see Gondolf, H. J. 

Surgeon, and anesthetist, relation to their patient, by Dr. Isidore Cohn 

Surgeon, industrial, some of the problems of, by Dr. David Walley 

Surgery, abdominal, personal experiences in emergencies, by Dr. Isidore Cohn 

Surgery, conservatism in, by Dr. J. F. Armstrong 

Surgery, general, new era, by Dr. W. H. Anderson 

Surgical treatment of arthritis, by Dr. John T. O’Ferrall 

Surgical treatment of pulmonary tuberculosis, by Dr. Alton Ochsner 

Syphilis and Diabetes — Editorial 

— T— 

Testimony, medical expert, by Hon. S. L. Herold 

Thiberge, N. F., — (joint author), see Scheppegrell, Williams 

Thompson, Gersham J., — (joint author), see Bumpus, Hermon C 

Thornhill, F. M., — Medical ethics 

Thyrotoxicosis, symptoms, early recognition, by Dr. A. G. Payne 

Townsend, J. G., — The full time health program developed in the Mississippi Valley fol- 
lowing the flood 

Toxemias of pregnancy, by Dr. John Osborne Polak 

Tuberculosis, by Dr. T. D. Bordeaux 

Tuberculosis, clinical value of neutrophile, lymphocyte and monocyte indices, by Dr. Wal- 
lace J. Durel 

Tuberculosis, control in infants and children, by Dr. Harvey F. Garrison 

Tuberculosis, distribution and extent of (Abstract) 

Tuberculosis, genital, by Dr. Hermon C. Bumpus and Dr Gersham J. Thompson 

Tuberculosis, pulmonary, surgical treatment, by Dr. Alton Ochsner 

Tucker, Hyman, — (joint author), see Cavanaugh, W. J 

Tularemia in sheep in nature (Abstract) 

Tularemia, review of literature, report of cases, by Dr. W. S. Kerlin 

Tumors, malignant of bone, roentgen-ray treatment, by Dr. C. P. Rutledge 

Tracheo-bronchitis, staphylococcic, following tonsilitis, by Dr. J. S. Ullman 

Traffic regulations, observation or disregard of (Abstract) 

Tryparsamide, late results from therapy in neuro-syphilis (Abstract) 

— U— 

Ullman, J. S., — Staphylococcic tracheo, bronchitis following* tonsilitis 

Unsworth, H. R., — Malaria therapy in paresis 

Uremia, the problems of, by Dr. J. H. Musser 

Uterine disease, treatment with radium, by Dr. Walter W. Crawford 

Uterine hemorrhages, their significance, by Dr. O. P. Daly 

Uterus, bicornate, by Dr. F. M. Lett 

— V— 

Vaccine, B. C. G., — Report on researches by Dr. A. Bocchini, translation with introduction by 

Dr. John Signorelli 

Varicose veins, and their sequelae (Abstract) 

Varicose veins, treatment by injection of sclerosing solutions, by Dr. iShirley C. Lyons and 

Dr. C. B. Brewster 

Varicose veins, treatment — Editorial 

Vicksburg Sanitarium and Crawford Street Hospital Transactions 218, 363, 445, 514, 

667, 758, 838, 


xiii 


667 

358 

566 

636 

140 

912 

331 

31 

735 

867 

281 

551 

471 

769 

899 

876 

835 


237 

337 

681 

855 

564 

245 

457 

824 

480 

96 

443 

681 

876 

290 

824 

723 

406 

311 

734 

30 


311 

167 

174 

474 

624 

918 


350 

741 

498 

929 

591 

933 


XIV 


Index 


— W— 

Walley, David, — Some of the problems of an industrial surgeon 281 

Walmsley, T. Semmes — The relation of the physician to the public 13 

Walther, H. W. E., — Modern treatment of gonorrhea 199 

Warren, J. W., — Report of 1,000 cases of hemorrhoids treated by office methods 902 

Weil, A. I., — The use of llpiodol as an aid to diagnosis of nasal sinus conditions. A prelim- 
inary report, by Dr. A. I. Weil and Dr. W. F. Henderson 426 

Weiss, C. A., — (joint author), see Efron, B. G 318 

Wiggers, C. J., — The value and limitations of laboratory methods in clinical investigations of 

cardiovascular disease 601 

Williams, C. T., — The diagnosis and treatment of celiac disease with report of two cases 647 

Williams, Lester J., — Hypertrophic pulmonary osteoarthropathy 708 

Williams, T. E.,— Digitalis 813 

Wolf, M., — Extra-genital chancre of the umbilicus 211 

Words, usage of — Editorial 510 

Wounds, by Dr. Alton Ochsner 746 

Wounds (Part II), by Alton Ochsner 826 

Wright, W. R., — Some essentials in a dental health program 703 

— Y— 

Yesterday and today in medicine, by Dr. J. Augustus Crisler 89 


Vol. 81 

THE EVOLUTION OF MEDICAL 

TEACHING IN NEW ORLEANS.* 

ERNEST S. LEWIS, M. D., 

New Orleans. 

The medical department of the Univer- 
sity of Louisiana, since 1834, now Tulane 
since 1884, is the oldest medical college in 
the southwest and had existed as a private 
institution since 1831. When merged in 
the University, it was its sole depart- 
ment; the law and academic being estab- 
lished later. 

The rights and privileges it possessed 
prior to the change were not materially 
affected, it was practically autonomous 
until during the deanship of Dr. Chaille, 
by faculty vote it became in deed, and in 
fact, an integral part of the university. 

I matriculated at the opening of the ses- 
sion of 1859-60, sixty-eight years ago. The 
teaching staff numbered nine, including 
two demonstrators of anatomy. There was 
no entrance examination, to read and write 
were the only requirements. Each profes- 
sor collected the fees for his lecture card, 
later this was assumed by the dean and 
after the surrender at the headquarters of 
the university. 

Two annual sessions of four months each 
were required for graduation. In 1879 it 
was extended to four and a half months. 


*This address and the following three addresses 
were delivered at the Semi-Centennial Anniver- 
sary of the Orleans Parish Medical Society, May 
7 , 1928 . 


No. 1 


a few years later to five, and in 1893 to 
six months; after 1909 to nine months. 

The course of instruction in my student 
days consisted in attendance on seven lec- 
tures daily, one of them clinical in the 
amphitheatre of the Charity Hospital, two 
hours of bedside clinics in the wards with 
no division of the students in classes until 
1869, and two hours of dissection in the 
laboratory of practical anatomy. I at- 
tended but one course of lectures having 
become an interne of the Charity Hospital 
at the close of the session which exempted 
me from attendance on lectures and was 
not regretted as I profited far more from 
my hospital experience. 

The examinations were oral until about 
1902, when written were required. Ignor- 
ance and illiteracy characterized the mental 
equipment of the majority of the student 
body, which did not improve until many 
years after the Civil War. The examina- 
tions were perfunctory and superficial, 
with but few rejections. 

No change occurred in the staff until 
11867 when a lecturer and instructor was 
appointed for eye and ear affections: a 
year later chiefs of clinics; in 1886, a lec- 
turer and clinical instructor for diseases 
of the skin; in 1887, a pharmaceutical 
laboratory for pharmacy students only; in 
1889, a laboratory of histology and bacte- 
riology and a demonstrator; in 1890, one 
lecturer and clinical instructor of physical 
diagnosis, and also one for diseases of 
children, and in 1891, one lecturer and 
clinical instructor on minor surgery. 


New Orleans Medical 

and 

Surgical Journal 

JULY, 1928 


2 


Lewis — The Evolution of Medical Teaching in New Orleans 


As Dr. Chaille states, from whose his- 
torical summary I obtained these data, the 
number of special studies in all branches 
of medicine taught were largely increased 
between 1885 and 1891, from 11 to 16, the 
laboratories fi'om 2 to 5, and the number 
of teachers from 19 to 41, and marked the 
first notable evidence of progress since 
1834. 

The only thing noteworthy from that 
date until 11909 was the admission of 
women to medical studies, to whom that 
privilege had been granted many years 
before in the pharmaceutical course. 

In 1903, the Richardson Memorial, now 
the Hutchinson, was completed and occu- 
pied, with well equipped laboratories of 
pharmacy, chemistry, practical anatomy, 
microscopic ond operative surgery. In 
1909, the Richardson Memorial, with its 
well equipped laboratories was opened and 
occupied for the use of the first and second 
course students, very much to their advan- 
tage in the study of the elementary 
branches. 

While progress continued slowly from 
1901, it assumed a phenomenal rise from 
1909 to the present day. The annual ses- 
sions were extended to four years of nine 
months courses each and for entrance re- 
quirements, a first-grade teacher’s certifi- 
cate and a year of academic studies, since 
increased to two years, and perhaps later 
to an academic degree, as required in some 
of the Northern colleges. 

Besides the changes mentioned was the 
infusion of new blood in the appointment 
of four men of distinction as chiefs of 
departments, two of whom still continue in 
the faculty. Two others of like distinction 
in the medical world were secured as chiefs 
of the Chairs of Medicine and Surgery, 
within recent dates, who will give their 
undivided attention to college work and not 
to outside practice as was heretofore per- 
mitted the chiefs of the practical chairs 
which was not to the best interests of the 
students and university; a wise and pro- 


gressive measure but recently adopted by 
the faculty and Board. 

The teaching facilities have been greatly 
enlarged ; there are in active operation, 
ten teaching and ten department labora- 
tories. The staff now numbers one hun- 
dred and fifty-one, disposed as follows: 
ten to anatomy, ten to physiology, five to 
materia medica and pharmacy, four to bio- 
chemistry, nine to pathology and bacte- 
riology, eight to pediatrics, forty-four to 
medicine, thirty-five to surgery, two to 
tropical medicine. This permits the divis- 
ion of students into small sections, which 
enables them to be more efficiently taught. 

Among the causes most effective in over- 
throwing preconceived notions, views and 
theories entertained and taught dogmati- 
cally in the schools regarding diseases of a 
contagious and infectious nature, was the 
discovery by Pasteur and other eminent 
scientists of the role of micro-organisms in 
their production, which established the 
germ theory of infections and contagions, 
conveyed in many instances by insect car- 
riers, as the mosquito, the flea, fly and 
other insects. 

This knowledge led to the destruction of 
the mosquito and its breeding places, ban- 
ished yellow fever from our midst, and the 
wholesale slaughter of rats and their flea 
carrier of bubonic infection, of which we 
had a few sporadic cases, no doubt pre- 
vented its spread. Furthermore, we 
learned to utilize our enemies, dead and 
alive, in manufacturing vaccines, anti- 
toxins, serums for immunization and cures 
as is done now every day in typhoid fever, 
rabies, diphtheria and other affections. 
The roentgen-ray having come into use 
shed further light on the organs of the 
cavities as to their relations, normality or 
abnormality and pathological states. Great 
strides have been made in regional studies, 
heart, lungs, digestive and other organs of 
the body, necessitating far more intensive 
study and instrumental skill, possible to ac- 
quire in the course of studies for the 
doctorate to attain efficiency, which of 


Fossier — The Earhj History of the Orleans Parish Medical Society 


3 


necessity developed specialization, as also 
the great advance along all lines of medi- 
cal teaching. 

In surgery and obstetrics bacteriological 
discoveries proved as revolutionary as in 
medicine after successful measures were 
adopted giving protection from infection. 

It extended the field of surgical activi- 
ties to the abdomen, removed the fear 
attending opening the peritoneal cavity 
which general fatalities attending on such 
operations in the past had endangered. 

Then followed an era of the most bril- 
liant achievements in surgical work, which 
raised surgery to the highest peak of glory. 
It was its renaissance and that of medicine 
and effected radical changes in medical and 
surgical teaching, with which this school 
kept pace and some of the earliest pioneer 
work in abdominal and gynesic surgery in 
the South was developed by one of its 
staff. 

So large had the field of medical studies 
extended that division of labor followed as 
a necessity, establishing specialties which 
side-tracked the family doctor and his ideal 
relations with the families in his clientele. 


Fear of Hospital Is Unwarranted. — Fear of the hospital 
should have no place in the mind of the modern citizen. 
In the days when medical science partook of the nature of 
witchcraft, mystery pervaded every branch of its practice. 
But the keynote of modern scientific medicine is confidence 
and hope. A hospital, therefore, is a place of sympathy 
and good feeling, a refuge in time of trouble. Mr. Oyler 
divides hospital critics into two groups: the wiseacres, who 
assume an air of omniscience when they really know little : 
and the timid of spirit, who are genuinely fearful. The 
hospital critic is inclined to compare the hospital unfavor- 
ably with his home, his club and his hotel. Mr. Oyler 
believes that if a fair comparison is made the critic will 
find that personal service is carried out to a surprising 
degree. The timid type of person is afraid because of the 
terrible stories he has heard of unpleasant experinces. 
Most of such stories are untrue or at least exaggerated. — 
Oyler-Weston, Hygeia, 6:28, 1928. 


THE EARLY HISTORY OF THE 
ORLEANS PARISH MEDICAL 
SOCIETY. 

A. E. FOSSIER, M. D., 

New Orleans. 

There are today, in the Orleans Parish 
Medical Society, just a few fortunate mem- 
bers, who can send recollections reverber- 
ating to the period of the incipiency of this 
Association. The more numerous, less 
favored, ones, became participants in its 
activities at different periods of its 
progress. 

I have assembled those earlier happen- 
ings, as well as the events of subsequent 
times, in the following modest historical 
review. 

The Orleans Parish Medical Society was 
organized in conformation to a resolution 
presented by Dr. Chaille at the first con- 
vention of the State Society on January 
14-15-16, of the year 1878: “That every 

member of this Association be charged 
with the duty of endeavoring to secure the 
organization of a medical society in each 
of the parishes of the State, prior to April, 
1879.” 

The birth of the Orleans Parish Medi- 
cal Society was heralded in the following 
editorial in the May issue of the New 
Orleans Medical and Surgical Journal for 
the year 1878, as follows: 

“A meeting of medical gentlemen was 
held on Monday evening, April 22, inst., 
to establish a parish medical society in 
affiliation with the State Medical Associa- 
tion. The meeting was well attended. The 
only action taken was the appointment of 
a temporary chairman. Dr. Logan, of a 
committee on permanent organization, viz: 
Drs. Chaille, Turpin and Herrick. This 
committee will report on Monday evening. 
May 6,* when it is hoped that the ob- 
jects of the meeting will be successfully 
accomplished.” 

And that Journal, for the following 
month, announced in an editorial entitled 


4 


Fossier— T/ ie Early History of the Orleans Parish Medical Society 


“Orleans Parish Medical Society,” that 
under this title a number of medical gen- 
tlemen have organized a society, which is 
to be affiliated with the State Medical 
Association. The president was Dr. 
Charles Turpin, and the Vice-Presidents 
were Drs. S. S. Herrick, Ernest Lewis, and 
J. F. Davidson. The secretaries were Dr. 
A. B. Miles and D. Jamison. 

Thus is recorded the first or organiza- 
tion meeting of the Orleans Parish Medical 
Society, which was held May 6, 1878. 

Dr. Chaille made the assertion, that 
most, if not all, of the forty-six physicians 
who were the first representatives of the 
Parish of Orleans to the State Medical 
Meeting were the founders of the Orleans 
Parish Medical Society. This role of honor 
comprises the following names : Drs. 

W. G. Austin, J. C. Beard, S. W. Bemiss, 
Henry Bezou, C. J. Bickman, W. P. Brewer, 
P. C. Boyer, J. C. Carter, S. E. Chaille, 
A. Chastant, Samuel Choppin, J. P. David- 
son, F. S. Drew, J. B. Davis, L. A. d’Es- 
tampes, C. Faget, G. C. Faget, J. A. G. 
Fisher, A. G. Friedrichs, G. B. Gaudet, 
A. P. Gourrier, S. L. Henry, S. S. Herrick, 
Joseph Holt, F. Jamison, Joseph Jones, 
Thomas Layton, Samuel Logan, J. P. 
Lehde, E. S. Lewis, F. Loeber, A. B. Miles, 
W. S. Mitchell, Geo. K. Pratt, T. G. Rich- 
ardson, M. E. Schlatter, F. D. Schmidt, 
M. Schuppert, L. F. Solomon, Howard 
Smith, H. S. Steinau, C. H. Tebault, C. 
Turpin, H. A. Veazie, J. M. Watkins. 

The circumstances leading to the organi- 
zation both of the State and Parish Socie- 
ties, as well as their purposes and aims, are 
so closely interwoven, that a history of the 
latter without a perusal of the former is 
incomplete. 

Due credit must be given to the Shreve- 
port Medical Society, and to the defunct 
Plaquemines Parish Medical Society, for 
sounding the clarion call, which assembled 
the representatives from the different 
parishes, for the purpose of organizing a 
State Society to conform to the plans of 
the American Medical Association. In an- 


swer to the appeal of these two societies, 
a circular letter calling a medical conven- 
tion to convene in the building of the Medi- 
cal department of the University of Lou- 
isiana, now the Tulane, on the 14th day of 
January, 1878, was issued from New Or- 
leans. Dr. Chaille wrote that after a 
session of three days, spent in perfecting 
an organization and preparing for efficient 
future action, the Society adjourned on 
the sixteenth of January, to meet in New 
Orleans, on Wednesday, April 9, 1879; and 
that the proceedings of “the first and only 
session” have been published. 

That year the Louisiana State Medical 
Society sent delegates to the convention of 
the American Medical Association, held at 
Buffalo, New York, and was represented for 
the first time in that body. An examina- 
tion of the Transactions of the American 
Medical Association shows that Dr. C. P. 
Langworthy and Dr. Ernest S. Lewis, were 
present at that meeting as representatives 
of the Louisiana State Medical Society. 
The Orleans Parish Medical Society was 
represented by Dr. S. L. Henry. Dr. T. G. 
Richardson was present as a permanent 
member of the Association, and was also 
its President. 

This history would be only an epitome 
of dry events, and the narration of unin- 
teresting facts, without a consideration of 
the motives, the sentiments and the 
reasons, which influenced not only its suc- 
cess, but its errors and frustations. It is 
also befitting that the prevailing condi- 
tions existing in the medical profession 
antedating the founding of the society be 
analized. 

We are greatly indebted to Joseph Holt 
for his fearless expose of the chaotic con- 
ditions existing prior to the advent of this 
Society, whose semi-centennial we are cele- 
brating tonight. His presidential address 
to the New Orleans Medical and Surgical 
Association delivered on December 2, 1882, 
is one of the most interesting documents 
in the annals of the history of the local 
profession. He said : 


Fossier — The Early History of the Oi leans Parish Medical Society 


5 


“Twelve years ago (1870) the only med- 
ical organization existing in New Orleans, 
after a few months of feverish and fretful 
life, died violently and was buried in 
merited obscurity, besides its predecessors; 
nearly all of tender age, none of them 
honored and regretted at their death. 
Anarchy reigned in our profession, and 
our wisest men had well nigh abandoned 
hope. Not only had the repeated attempts 
to establish a permanent organization 
failed, and this time disgracefully; but like 
noxious weeds, these left behind them 
baneful seeds scattered broadcast upon 
the fertile soil of our worse selves. 
They sprouted and grew and brought 
forth fruits — hatreds, incriminations and 
recriminations, back - biting, quarrelling, 
strife, and all manner of uncharitable- 
ness. Even casual conversation was bur- 
dened with the recital of some injurious 
story or severe criticism of another. With 
a few exceptions of personal predilection, 
physicians avoided each other with sus- 
picion and contempt. The spirit of Esau 
possessed us.” 

A retrospection, although difficult be- 
cause of the scarcity of medical news of 
that time, will show that the profession 
was divided into two camps : the dissenters, 
and the oligarchy. The former were prin- 
cipally recruited from the younger doc- 
tors, whose liberality and independence is 
to be greatly commended, because, today, 
we are indebted to them for the high 
standard of ethics, the amicable relation- 
ship and the spirit of tolerance, which have 
prevailed in the profession of this city 
many years. The latter, the oligarchy, 
who judging from the remaining records 
of that time, from the writings of Dr. 
Joseph Holt, a contemporary, and from an 
analysis of the roster of the officers and 
members of the New Orleans Medical and 
Surgical Association, for the year 1873, it is 
logical to assert, was composed principally 
of the older doctors and the teachers of the 
Medical College. Dr. Holt further tells us : 
“that the only notion of an Association that 
coterie had, was based on a huge consti- 


tution; a lot of statutory laws, called by 
them a code of ethics, which, among other 
things, provided for the establishment of 
an amusing little tribunal, a sublime 
mimicry of magisterial dignity, called a 
court medical, or some such terrifying 
title, that proved as effective as a Chinese 
gong in a battle; a sort of criminal court 
or inquisitorial judiciary, composed of a 
set of doctors, some of whom were refresh- 
ingly immaculate and peculiarly qualified 
as censors. These were to say whether a 
man was to be humbled and declared in 
public disgraced, or acquitted, or pardoned. 
They could disgrace but could not ex- 
alt— jealousy forbade! However, the code 
was all right; the only one all wrong was 
the egregious simpleton who deliberately 
permitted any set of men such extraordi- 
nary authority over himself: selling his 
birthright for less than a mess of pottage. 
But they did do it! and history has re- 
corded that the very men who were fore- 
most in enacting the laws were the first to 
defy them.” 

In 1873, a few of the most progressive 
and active members of the profession re- 
belled against the prevailing conditions, 
and with the hope of accomplishing the 
much needed reforms, established the New 
Orleans Medical and Surgical Association. 
Those young men who held the meeting in 
which that society was conceived were rev- 
olutionists. Their coup d'etat liberated the 
profession from an obnoxious code of 
ethics which provided an immunity to a 
privileged coterie, whilst exerting unrea- 
sonable constraint on a less favorable 
majority. 

From an editorial in the New Orleans 
Medical and Surgical Journal for the 
month of March, 1874, the following is 
quoted : 

“During the latter part of last year 
some of the physicians of this city de- 
termined to found a new medical associ- 
ation, who thus seem to have resolved 
that the supiness of their seniors should 
not become a reproach to them.” 


6 


Fossier — The Early History of the Orleans Parish Medical Society 


The reproof of these young men is ex- 
pressed in the opening clause of their 
constitution and rules written in 1873, 
which reads: “For the mutual improve- 

ment, instruction and interchange of opin- 
ions and observations, the discussion of 
medical subjects, and the cultivation of 
kindly feelings among the members of the 
medical profession of New Orleans, the 
founding of a medical association is 
deemed advisable.” The constitution that 
was framed claimed no authority outside 
of the meeting room, and exacted nothing 
more than regularity of attendance, the 
payment of dues, and the opening of dis- 
cussion when appointed. The only pro- 
visions for membership were that an indi- 
vidual proposed must be a regular grad- 
uate of medicine, of good moral standing; 
and that a proven violation of the criminal 
law of the land was ipso facto an expul- 
sion. The following were the signers of 
that declaration of independence: Drs. 

F. Loeber, President, and W. H. Watkins, 
Secretary. W. P. Brewer, J. J. Castella- 
nos, J. M. Cullen, Oscar Czarnowski, L. G. 
Durr, C. A. Gaudet, V. Grima, S. S. Her- 
rick, Joseph Holt, R. R. Hopkins, Frank 
Hawthorn, 0. R. Lanng, Y. R. Lemonnier, 
Sam Logan, L. F. Solomon, R. J. Mainegra, 
L. S. McMurty, 0. W. Perry, A. Pettit, Jos. 
Schmittle, F. T. Shepard, E. Souchon, 
Warren Stone. 

It is a fact that, with the birth of the 
New Orleans Medical and Surgical Associ- 
ation, there also came into existence a 
kindlier feeling among physicians, and a 
renaissance of scientific activities. We 
may tonight repeat the words of Dr. Joseph 
Holt, that a great work has been accom- 
plished; a great change wrought; silently, 
slowly, almost imperceptible. So great a 
change has taken place, indeed, that the 
medical profession in New Orleans of to- 
day, is no more like that of ten years ago, 
and we may add, sixty years ago, than 
peace and quiet, and contentment of mind, 
are like the wrangling of passions and 
perditions. 


The first nine years of the existence of 
the Orleans Parish Medical Society were 
uneventful. It was somnolent. Its contri- 
butions to the medical literature of the day 
were scant. Its meetings were not regu- 
larly attended, because of the neglectful 
indifference of its membership. The same 
lethargy prevailed in the Louisiana State 
Medical Society. There were barely fifty 
members in the Parish Medical Society at 
the end of the year 1886, evidencing that 
it had not grown in membership during 
the first eight years of its existence. 

A few of the younger doctors sensing that 
a strong active medical society would re- 
dound to the greater good of the profession, 
attempted to rejuvenate the Orleans Parish 
Medical Society. With this end in view 
they thought that Dr. Davidson, the Nestor 
of the profession of that time, beloved by 
all his confreres, especially the younger 
ones, was the logical individual to accom- 
plish it. At the annual meeting in March, 
1887, they elected him to the presidency 
of the Parish Society, and Dr. Chassaignac 
was selected secretary in order to assist in 
the more active duties. 

Dr. Chassaignac wrote that at that time, 
the few members who still took an active 
interest in the two societies, having re- 
alized that they were the ones who were 
chiefly supporting the Orleans Parish 
Medical Society, as well as the New Or- 
leans Medical and Surgical Association, 
which also had fallen into a state of in- 
nocuous dessuetude, after having been 
prosperous and very active for many 
years, came to the conclusion that this was 
a waste of energy and time, and that the 
two societies should be consolidated. For 
this purpose a committee was appointed to 
confer with the New Orleans Medical and 
Surgical Association. In April, 1887, this 
committee reported that it had offered the 
New Orleans Medical and Surgical Associ- 
ation to resign everything to it and to 
become part and parcel of the Association, 
provided it became affiliated with the State 
and National Association, thereby adopting 


Fossier — The Early History of the Orleans Parish Medical Society 


7 


their code of ethics. A majority favored 
the amalgamation, but as it failed to re- 
ceive unanimous sanction, the committee 
was in favor of dropping the matter. 

The year 1890, however, was notable for 
the achievement of the unification of the 
medical societies of the city. The New 
Orleans Medical and Surgical Association 
having disbanded, donated the balance of 
its funds, about $60.00, to the Medical 
Library Association, which shortly after, 
also became absorbed by this society. Dr. 
Chassaignac stated that the Orleans Parish 
Medical Society thus became the only 
medical society here and included all the 
local men who showed an active interest 
in medical matters and organization. 

The same blight seems to have affected 
the Parish and State Societies, and it is 
more than a coincidence, that this amalga- 
mation was the needed stimulus which in- 
jected the virility and enthusiasm which 
spelled the success of both organizations. 

Dr. Bemiss and Layton read papers at 
the first scientific meeting of the society 
held June 24, 1878. 

We are indebted to the activities of the 
following members for the survival of the 
Society through the first years of its ex- 
istence : Drs. Bemiss, Chaille, Choppin, 

Cullen, Bickham, Copes, Davidson, Faget, 
Herrick, Henry, Jones, Friedrichs, Levy, 
Layton, Lewis, Miles, Pratt, McCutcheon, 
Lawreson, Schmidt, Turpin and W. 
Watkins. 

A rejuvenation of the Society took place 
in 1887, when Dr. Davidson was elected 
President and Dr. Chas. Chassaignac, 
Secretary. From that time authentic 
records were kept of the Society’s trans- 
actions. 

The Society discussed for the first time 
the question of hospital abuse. May 18, 
1890. The same day the house warming 
of its first home took place. A dream was 
realized, and an old but overwhelming 
ambition was at last achieved. It had dis- 
pirited and vexed the members not to 


own their own home, and so be forced to 
dependence upon others. This fact is at- 
tested by a report of the domicile com- 
mittee of that year, which said: 

“It is greatly desirable that this Society 
should have a place of meeting of its own, 
either by rental or purchase, and not be 
dependent upon the good will and gener- 
osity of others.” 

The home was an independent, one-story 
building, which consisted of two large 
rooms and a wide hall, situated on Univer- 
sity Place, half a block from Canal, which 
was formerly the office of Dr. Joseph 
Jones. The place was leased for the 
modest rental of $20.00 per month. In 
order to finance the new home, the dues 
were raised from $5.00 to $12.00 per year. 
The membership totaled about 140 mem- 
bers. Dr. Callan was then president. Dr. 
Fomento, chairman of the domicile com- 
mittee, in his report to the Society, on that 
night, said: 

“I am happy to add that my distin- 
guished friend and right bower. Dr. E. D. 
Martin, has consented to act as godfather 
to the newly born. May we not properly 
apply to him the French proverb: ‘Un 
parrain est un second pere I’orsqu’il n’est 
past le premier.’ ” 

If this city is to achieve pre-eminence as 
a medical center, it will be the result of 
three essential factors : schools of medi- 
cine, a great hospital having almost un- 
limited facilities, and the last but not 
least, a medical library. 

The history of this Society would be in- 
complete without mention of its library. 
Its evolution is interesting. 

In 1887, a medical library was organ- 
ized in this city intended for the use of 
physicians and pharmacists. It was called 
the “Louisiana Medical Library Associa- 
tion.” It was housed in the Medical Col- 
lege of Tulane University. The dues were 
$5.00 per annum. Only 39 physicians 
availed themselves of the privilege of 
membership. A contemporary editorial 


8 


Fossier — The Early History of the Orleans Parish Medical Society 


tells us that: “The medical library be- 

longing to the Tulane University will be 
brought down from its hiding place in the 
garret of the Tulane Hall, and with the 
acquired and loaned volumes of the Library 
Association, will form a very respectable 
beginning of a library which should and 
which we believe will steadily increase in 
usefulness to the profession of Louisiana.” 
The officers of the Library Association 
were Drs. H. W. Blanc, President, Ed- 
mond Souchon, Vice-President, and A. Mc- 
Shane, Secretary. 

The Library Association proffered to 
surrender its library to this Society in 
December, 1889, providing the latter as- 
sumed all responsibilities, employed a libra- 
rian and admitted to membership its 
members. The first standing committee 
on Library was created at that meeting. 

Dr. Blanc, the founder of the Library 
Association, is in reality the father of the 
library, but due honor should be given to 
Dr. Davidson, then President, and to his 
young Secretary, Dr. Chassaignac, for 
their vision in agitating its formation. The 
absorption of the library by the Orleans 
Parish Medical Society was heralded as an 
important event in the history of Medicine 
of this city, because it brought together in 
one organization all the local medical men 
who took an active interest in the welfare 
and progress of their profession. Dr. 
S. P. Delaup was the first librarian. 

Dr. Parham in his presidential report 
for the year 1895 said : “The phenominal 

increase will be understood when I tell you 
that in July, 1893, there were only 121 
bound volumes in the library; by Decem- 
ber, 1893, five volumes were purchased and 
152 volumes were donated by Drs. Chas- 
saignac and deRoaldes. In 1894, unfortu- 
nately, the Librarian made no report, but 
it appears that the library was in a slug- 
gish state during that year. The moving 
into new quarters infused new life. Here 
are some of the items : 


Purchases at U. S. Barracks, at 10 


cents per volume, bound 250 

Donated by Dr. Bruns 216 

Donated by Mrs. W. P. Schuppert 550 

Donated by Dr. W. E. Brickell 39 


and a number of smaller donations, making 
1342 bound and 130 unbound volumes 
added during 1895.” 

The indexing of the library began in 
1893. Dr. Delaup reported that when he 
assumed the duties of librarian in 1891, 
he found a catalogue without a single 
entry, a lot of medical journals and other 
pamphlets thrown promiscuously on the 
top of high shelves, a few weeklies and 
monthlies on the stand, and an infinite 
number of bound volumes in nearly every 
room of Tulane Hall. 

In 1904, through Dr. Chassaignac, the 
New Orleans Polyclinic donated 1400 
volumes to the library, and in 1921, Mrs. 
William Kohlman presented to the Society 
about one thousand volumes, the library 
of her distinguished husband. 

In 1907, the members were permitted, 
for a limited period of time, to take the 
books to their homes. 

From this humble beginning grew our 
present library. Its days of uncertainty 
are passed. Its growth will be rapid, its 
future assured. It has an endowment of 
$10,000.00, and receives approximately 150 
new books from the best publishers of 
this country and Europe without cost, be- 
cause of a clause of the agreement of the 
gift of the New Orleans Medical and Sur- 
gical Journal to the State Society by the 
Committee on Arrangments of the 1920 
Convention of the American Medical As- 
sociation, that all books sent to the journal 
for review must be given to the library. 

It contains today, approximately, 16,000 
volumes, of which 14,365 are bound 
volumes. This library is the most treas- 
ured possession of the Society. 

The Society soon outgrew its first domi- 
cile. Many of its presidents stressed the 


Fossier — The Early History of the Orleans Parish Medical Society 


9 


necessity of the Society owning its own 
home. President Magruder, in his inau- 
gural address, forcefully urged this need, 
hear what he said: “The one thing now 

of permanent importance to us is a domi- 
cile, and I say to you here tonight, look 
about you and see if this meeting room is 
a credit to the Medical Profession of New 
Orleans. No, it is not, and there is no 
reason why we should remain in such quar- 
ters. While we have not the wealth of 
some of our Northern neighbors, surely it 
cannot be said that among more than 200 
physicians here, not enough money could 
be raised to purchase and maintain a 
proper domicile that would be a credit and 
an honor to us. We are stronger than ever 
before and action should not be longer 
deferred.” 

A dream of twenty years had at last 
been realized. November 12, 1904, the 
Society met for the first time in its own 
home. 

The three-story building on Elks’ Place, 
corner of Cleveland avenue, was pur- 
chased for $5,000.00. A true house warm- 
ing celebrated the occasion. Drs. Chaille, 
Joseph Holt and Rudolph Matas were the 
orators on that occasion. 

Again the Society soon outgrew its 
quarters. Dr. Granger in his presidential 
report for the year 1908, agitated the 
question of a larger domicile, with more 
sitting room, and with a larger shelving 
space for books, in short, one more com- 
fortable to a society of this size and 
importance. And Dr. Seeman in his inau- 
gural presidential address asserted that: 
“The present domicile of the Society is 
unfit in size, condition, and arrangement 
to house for a much longer period this 
Society, numbering as it does nearly 300 
members, and some steps should be taken 
to better this condition.” 

On the same site a building was erected, 
and on March 13, 1911, the house warming 
meeting was held. Drs. Chaille and Chas- 
saignac were the historians of that night. 
Dr. Ledbetter was the President, and to his 


efforts is largely ascribable the erection of 
the new building. 

Insufficient revenues added to a large 
mortgage, plunged the Society into finan- 
cial distress, and it was soon confronted 
with the alternative either of selling its 
building or of having bankruptcy thrust 
upon it. Dr. Fossier suggested that the 
only way out of the difficulty was to give 
a benefit to the end that the much needed 
funds to save the credit of the organiza- 
tion could be more quickly procured. A 
committee headed by Dr. Fosser, with 
Drs. Homer Dupuy and Paul Gelpi, as- 
sisted by every member of the Society, 
gave a concert for the “Benefit of the Or- 
leans Parish Medical Society Library 
Fund” at the Athenaeum, January 27, 
1917. Over $5000.00 was realized from 
the program and the entertainment, and 
after paying pressing debts, the bonded 
indebtedness was reduced by $3300.00. 
There were still outstanding bonds to the 
value of $16,500.00. 

Shortly afterwards, during the adminis- 
tration of Dr. Bernadas, and greatly 
through his efforts, the site was sold to 
the Elks’ Club for $50,000.00. 

Time does not permit me to relate some 
of the most important episodes in the his- 
tory of the Society; but mention must be 
made of these periods of dire calamity, 
when uncertainty, despair and fear hung as 
a pall over a proud city. Who more than 
the members of this Society realized the 
seriousness of the situation and the futility 
of human efforts to repel the unknown and 
invisible attacks of the insidious enemy? 
Yet grave dangers lurked and menaced the 
very existence of their patients, friends 
and loved ones, the destruction of the 
commerce of their city was imminent, and 
communication with the outside world was 
barred by the yellow flag and the unrelent- 
ing watch of the sentinel. With despair they 
would assemble to offer suggestions and to 
discuss ways and means by which the 
plagues could be eradicated. 


10 


Patton — Personal Recollections 


A volume could be written on these 
symposiums, which are examplications of 
the stupendous progress of preventive 
medicine in the recent pass. In these 
fifty years of our existence, the era of the 
greatest medical advancement in the an- 
nals of mankind, the Orleans Parish 
Medical Society has always kept pace with 
the march of progress. 

This Society is the repertory of the tra- 
dition, lore, culture and learning of a noble 
profession. It is still in its early infancy, 
but its future is assured, because of the 
stability of its foundation, built, as it is, 
on the rock of experience, adversity and 
service to suffering humanity. Its perma- 
nency may be assailed at just one point. 
Bearing on this subject, and warning of 
its dangers, our well-beloved John Archin- 
ard. President for the year 1907, said : 

“In my inaugural address, I inveighed 
against cliques, or combines that jeopard- 
ize the integrity and welfare of our society, 
in order to promote selfish ends, further 
private interest, satisfy bounding ambi- 
tion, or wreak vengeance for being out- 
stripped in honorable competition for con- 
trol of the affairs of the organization, and 
I deem it proper at the closure of tenure 
of office to again raise my voice, in no un- 
certain tones, against the menace. Believe 
me, gentlemen, I can truthfully say of our 
Society, equipped as it is, as Macauley did 
of America : Tf she be destroyed, it will 

not be by any power without, it will be by 
the Huns within.’ ’’ 


Medical-Electrical- Pharmaceutical Exposition in Mexico 
City. — Mr. Ignacio Ocampo y A. publisher of the Journal 
of the Mexican Medical Association and the Bulletin of the 
Mexican Society of Radiology, and Mr. Frederick E. Storm, 
colaborator of the Mexican Medical Directory and represen- 
tative in Mexico of the American Medical Association, are 
organizing a Medical-Electrical-Pharmaceutical Exposition 
and Convention, which will take place October next is 
Mexico City. The Exposition will be held under the aus- 
pices of the President of the Republic, General Flutarco 
Elias Calles : the Secretary of Education, the Mexican Medi- 
cal Association, the Society of Electro-Radiology, the Na- 
tional University, The Health Department, etc., and great 
efforts are being made by the organizers to make this an 
attractive and popular event, not only to the medical and 
pharmaceutical profession, but also to the public in general. 


PERSONAL RECOLLECTIONS. 

G. FARRAR PATTON, M. D„ 

New Orleans. 

My very noble and approved good mas- 
ters.” To paraphrase further the apology 
of Othello before the Senate of Venice: 
That our honored, learned and eloquent 
brother. Dr. Matas, is absent, is alas, most 
true. True, also, that by the gracious invi- 
tation of our Committee, I am here to speak 
in his place, however unworthy of that high 
honor. Under the circumstances, it would 
be vain on my part to attempt the role of 
actually representing Dr. Matas, but as it is 
understood to be his wish that I should re- 
view conditions existing at the time the old 
Medical and Surgical Association was 
merged into this Society, I shall endeavor, 
briefly, to set the facts of the case before 
you. 

At the time that this Society was or- 
ganized, as described by Dr. Fossier, the 
New Oreans Medical and Surgical Associ- 
ation was a vigorous and earnest body of 
men, and so far as concerns this present 
generation, was the pioneer organization 
of medical men in this city. It was but a 
small body of men, probably less than one 
hundred, but a body more enthusiastically 
devoted to the objects of their association 
I have never known. There was a meeting 
every Saturday night and there was 
always something doing. 

A few years after this Society was 
formed, it began to be realized that there 
was seemingly no need for two dis- 
tinct medical organizations in New Orleans, 
both carried on by practically the same 
men, and with the growth of that sentiment 
negotiations were set on foot to bring about 
a merging of the two into one strong and 
representative Society. A suitable letter 
was circulated asking for an expression of 
individual opinion on the subject, and as 
there appeared to be a strong sentiment 
favoring such a merger, a joint meeting 
was called to consider the question. Among 
other reasons for such action was the de- 


Patton — Personal Recollections 


11 


sire, strongly advocated by Dr. Chaille, to 
have the profession in New Orleans or- 
ganized on strictly ethical lines, the Parish 
Society to be a unit in the State Medical 
Association, and our State to become 
thereby definitely affiliated with the grow- 
ing American Medical Association. It is to 
be noted here that the old Medical and Sur- 
gical Association, however admirable and 
devoted, pointedly disavowed any obliga- 
tion to the accepted Code of Ethics, though 
I do not remember any non-ethical man 
being admitted to membership. 

Altogether, it is not surprising that in 
the old Association there was a small 
group of men, a sort of ‘‘Old Guard,” who 
were bitterly opposed to the proposed 
coalition, which meant the death of their 
beloved Society. Among those was a cer- 
tain prominent physician who had seem- 
ingly ignored the circular letter and who 
came to the joint meeting with war in his 
eyes, where, after being called to order 
four or five times because he persisted in 
talking, he finally rose and shook the dust 
off his feet, declaring he would never 
darken the doors again. 

Despite all opposition, spoken or un- 
spoken, the merger was duly carried 
through, with the results that we are here 
tonight to celebrate the Golden Jubilee of 
our own beloved Society, with its more 
than five hundred members and every pros- 
pect of a glorious future. 

But if you will pardon a slight digres- 
sion in memory of the old Association, I 
shall briefiy tell you of one of its charming 
customs. There used to be an annual din- 
ner, somewhere in mid-winter, to which 
the members were privileged to bring a 
guest, or more than one if willing to pay 
for them. We all sat at a long table, and 
the invited guests were expected to con- 
tribute to the general entertainment. 
There was a toastmaster who had kindly 
told those to be called upon the nature of 
the sentiment to which each would be 
asked to respond. This gave a certain zest 
of expectation to the atmosphere. 


On one such occasion we had with us 
the jovial Rabbi Leucht, who possessed, as 
those of you who knew him will remember, 
a keen sense of humor. When he rose to 
respond to the call of the toast-master, he 
looked all around the room and then 
solemnly said : ‘‘Mr. Chairman, I cer- 

tainly feel lonesome at this festive board. 
I find that I am the only preacher here. 
My friend. Dr. Loeber, who invited me, has 
as you know, a large Jewish practice, and 
I quite expected that for like reasons every 
other doctor would bring his pet preacher, 
but I look in vain for another in this room, 
so that I find myself stranded — marooned 
on an island of doctors.” 

But the most memorable instance of that 
kind was the presence on another occasion 
of a Colonel Glenn, a Texas Confederate 
colonel, who, in some unexplained way, 
had secured the appointment of Superin- 
tendent of Construction in the Custom 
House. Dr. Wm. H. Watkins, Chairman 
at the banquet, had invited the colonel, and 
when he rose to speak respectful silence 
was accorded him. He began by calling 
the waiter, whom he told, pointing to two 
caraffes of water, “Waiter, remove that 
objectionable liquid.” As that order was 
being obeyed, he began to place in a semi- 
circle before him all the partly emptied 
wine glasses in reach. Still dead silence. 
At length, he drew from his pocket his 
card of invitation and addressing the 
Chairman, said: “Mr. Chairman and Gen- 
tlemen : Now that I have rid myself of 

the sight of that objectionable liquid, for 
which I have never had any use as drink- 
ing material, and have in front of me a 
cordon of that other liquid upon which I 
have learned to rely, I feel emboldened to 
address this meeting. When I received 
this card of invitation from my friend 
Watkins, I was greatly pleased, because I 
felt sure that you doctors, however much 
you give nasty doses to other people, know 
how to provide good food and drink for 
yourselves. But when I discovered, here in 
the lower left hand corner of the card cer- 
tain mysterious, cabalistic letters, R.S.V.P., 


12 


Patton — Personal Recollections 


I was troubled with doubt as to whether 
they might no imply some condition with 
which I could not comply. In this dilemma I 
went to good old Aleck Finlay, who knows 
all the doctors and their ways, and asked 
him to tell me, if he could, just what those 
letters meant. Well, he laughed at me 
and said, ‘Why don’t you understand? 
R. S. V. P., coming after Watkins’ name 
means Royal Stag of the Victualizing 
Party.’ 

“Gentlemen, let me tell you further, that 
all my life, up to tonight, I have stood in 
fear and dread of your profession. In 
earliest childhood the mention of a doctor 
always inspired nameless fear, while the 
sight of one was almost enough to throw 
me into a fit, but now that I have met you, 
individually and collectively under the be- 
nign influence of a state of partial intoxi- 
cation, I know you for men and brothers, 
and I am not afraid of you any more.” 
Needless to say. Col. Glenn was solid for 
many future invitations. 

The Orleans Parish Medical Society did 
not immediately take up the pleasant cus- 
tom of having an annual dinner, but we 
have always had an annual orator, prefer- 
ably some distinguished man from outside 
our ranks, a selection that occasionally 
gave cause for serious debate. One year, 
when the time came to nominate an orator. 
Dr. Austin, a venerable member, proposed 
the name of a fine pulpit orator who was 
then rector of Trinity Episcopal Church, 
whose reputation the doctor declared was 
known from Maine to Florida. But Dr. 
Chaille raised the objection that it would 
be but a poor compliment to invite such 
a man to come and address a small gath- 
ering, such as our annual meeting. To this 
Dr. Austin replied that we could engage a 
suitable hall and insure an audience by ex- 
tending a general invitation to our friends. 

Dr. Chaille still objected, reminding us 
that on a previous occasion he had secured 
as an orator the greatest lawyer and the 
best orator in the State, Hon. Thos. J. 
Semmes, and that at the meeting, held in 


the Grunewald Hall, less than seventy-five 
people had been present. 

Dr. Austin then withdrew his nomina- 
tion and on the suggestion that an orator 
be chosen from our membership, the name 
of Dr. T. S. Dabney, a bright and capable 
man, was put in nomination. But here Dr. 
Dabney rose to object, declaring that, 
although his reputation as an orator had 
probably not reached as far as Kenner, his 
sense of self-respect would hardly permit 
him to accept that nomination after all that 
had been said on the subject. However, 
he was prevailed upon to accept, but never 
delivered the address because he was later 
appointed a member of the Board of Ex- 
aminers of the U. S. Pension Board and 
moved to Washington, so that it fell to 
my lot to speak in his place, just as I am 
doing here tonight. 

Really, if it were not for the moral and 
spiritual uplift of which I am conscious in 
responding to the flattering invitation of 
the Committee, I might be tempted to feel 
that my presence on this platform, instead 
of in the back row of seats, may be in ac- 
cordance with the prevailing idea that in 
an emergency, any old doctor will do. 

In the course of that address, I expressed 
the wish and the hope as to an ideal future 
for this Society that it might by its influ- 
ence become “a column of cloud by day 
and a pillar of fire by night” to guide our 
people struggling to escape from the wil- 
derness of disease, while awaiting the 
coming of the Moses and the Aaron who 
were destined to lead us out of captivity ; 
to rescue us and our children from the 
bondage of pestilence, with its heritage of 
untimely death. That hope has not been 
in vain. Those men have come, and one 
by one we have been able to vanquish cer- 
tain deadly diseases which so long held the 
human race in helpless subjection. 

I have not many years to live, so that I 
may not hope to witness the future tri- 
umphs of medical science, but I shall be 
content to “depart in peace, now that mine 
eyes have beheld the glory of the Lord” as 


Walmsley — The Relation of the Physician to the Public 


13 


revealed in medical progress. Am I con- 
scious of anything like stage-fright in thus 
addressing such an audience? Certainly 
not! In speaking to you this evening I 
simply feel that I am talking to a group 
of younger brothers and sisters, and when 
I look into your earnest, friendly faces, my 
heart goes out to you in fraternal affection, 
mingled with a glow of pride that I, too, 
am a soldier in your ranks, if perchance, 
only a corporal. 

Speaking for myself, I will say that 
when this Society shall again acquire its 
own domicile, if still living, I should like 
to see, displayed upon its walls in letters 
of gold the Psalmist’s words: Ecce quam 
honum, quamque juc-andum, habitare fra- 
tres in unum.f “Behold how good and 
pleasant it is for brothers to dwell to- 
gether in unity.” Surely a fitting motto 
for this Society, and one that all should 
seriously take to heart. To men and 
women like those gathered here tonight 
there can be no more inspiring thought 
than the realization of what is meant by 
those words of wisdom that have come 
down to us unchanged through the passing 
of centuries, assuring those thus pledged 
to our sacred calling that for our own 
sakes and for the success of our work, it 
is “Good and pleasant for brothers to dwell 
together in unity.” 

tl33 Psalm. 


World Child-Labor Standards. — Eighteen countries have 
ratified the draft convention adopted by the International 
Labor Office and submitted to the member nations of the 
League of Nations, wh'ch places the minimum age for 
entrance into industry at 14 years, and 20 countries have 
ratified that prohibiting night work of minors under 18 in 
industry, with certain exceptions for those over 16. 


THE RELATION OF THE PHYSICIAN 
TO THE PUBLIC. 

T. SEMMES WALMSLEY, 

New Orleans. 

It is indeed a pleasure to be asked to 
come to this meeting, because since 1920 it 
has been my privilege to become acquainted 
with a great number of medical men of the 
State, and particularly of the City of New 
Orleans. I feel that I have become part 
and parcel of the medical profession dur- 
ing that time. But it is indeed a greater 
pleasure to come on such a joyous occasion 
and to see the improvement that has been 
made by this Society which now has over 
five hundred members. You have a right 
to be proud of it. 

There is one thing that struck me most 
forcibly in listening to the addresses to- 
night, and that was that this Society has 
recognized the obligation that it owes to 
the public. It is a great thing for a doc- 
tor to be able to say that he is able to cure 
the sick, to be able to alleviate pain and 
suffering. But is that all that that doctor 
owes to the community? Has he filled his 
entire obligation when he has cured the 
sick upon whom he has to call? According 
to my views and concepts of a doctor’s 
obligation, and according to my views of 
the obligation of the State and Parish 
Medical Society; they have a greater obli- 
gation to perform. The State, the public 
at large have placed in their hands the 
administration of the Medical Practice Act. 
The State, the public at large, have en- 
trusted to them, not only the administra- 
tion of that Act, but it looks to the medical 
profession to protect the public from im- 
posters, from quacks, from people of all 
kinds who would prey upon the credulity 
cf the public in an effort to obtain from 
them a certain amount of cash. How can 
the public know those things that are legiti- 
mate cures? How can the public believe 
those things that we read in the Press as 
miraculous cures, wonderful operations 
performed? We must rely entirely upon 
the advice and the assistance of physicians 


14 


Walmsley — The Relation of the Physician to the Public 


ana surgeons to ten tne truth to the public 
and to keep them fully informed of de- 
velopments — not only is that your obliga- 
tion, but it is likewise your obligation to 
see that those men who are designated by 
your Society to carry out the purposes of 
the Medical Practice Act are kept fully in- 
formed of things that come to your notice. 
It might well be that you would feel that 
a doctor who might have given too much 
morphin, or who might prescribe too 
much cocaine should not be reported to 
them, but it is my idea of your duty as 
doctors when occasions of that kind come 
to your notice to report it to the State 
Board of Medical Examiners to take 
proper action. It might not conform with 
your ideas of ethics. It might be that you 
would believe it to be your duty not to 
divulge those things that come to your at- 
tention what another doctor has done, but 
you owe a greater obligation to the com- 
munity, State and nation to at least have 
that instance investigated by the proper 
parties, who have been designated by your 
association and appointed by the Governor 
to make those investigations. You must 
remember that the public has placed a halo 
about you, that they have given you untold 
protection, that they are permitting you 
experiments upon the lives of the people of 
the State, and they in turn have the right 
to demand of you that same protection from 
the quacks and those people who should not 
be administering to the public. You 
might well say : What is the practice of 

medicine? All seem to understand it, but 
the Legislature has defined what is the 
practice of medicine and they have gone 
much further than what the average man 
can imagine. 

So you see there is practically nothing 
that you can do, even the mere laying of 
your hands on a person to try and 
straighten out the end of your little finger, 
which is not practically the practice of 
medicine. Since you have had this en- 
tire — well you might say laying of your 
hands upon the public of the State — made 
sacred unto you, there is the obligation to 


safeguard the public at large from all 
persons who try to do things that do not 
come within the terms of this Act. 

One of the most striking things that I 
have heard in my life came to my notice 
today, and the remedy to my mind will 
have to come from the physicians. We were 
discussing the question of the new Jail and 
Parish Prison in the Council Chamber and 
Dr. Hart was asked the question if pro- 
hibition did not provide more violators for 
the Federal prisons than any other class 
of people. He said it is remarkable to 
know that this is not the case, but that 
sixty per cent of the inmates of the Fed- 
ex'al penitentiary today are there for 
violation of the Harrison Narcotic Act. 
Sixty per cent are, therefore, drug addicts 
or those selling or dealing in drugs. It 
was startling to know It was astounding 
to every member of the Council. At the 
time I heard it I made mental reservation 
to mention it tonight. The lawmakers 
cannot find a solution apparently for this 
problem ; that will have to come from the 
medical men. You will have to make the 
decision as to what the remedy shall be. 
The lawmakers are willing to recognize 
that they have failed so far in dealing 
with this problem, but it is up to you to 
devote your time and study to lifting this 
dreadful curse from this nation. To my 
mind, unless this curse is taken away 
from this country, it will not be long be- 
fore its ravages will be felt in every home. 
It is hard to really realize the purport of 
a statement of that sort, but when you 
begin to realize how great the spread has 
been in this counti’y in the last years and 
when you begin to realize that sixty per 
cent of the Federal prisoners are there for 
that reason, you must realize there is no 
greater problem confronting the medical 
profession than working out the solution 
of this problem for the public. 

The public does not expect the medical 
profession to run around seeking various 
people who are violating this Act, but it 
does expect that when these things come to 


McCormac — A Study of Tuberculous Adenitis 


15 


your attention thot you will do your part. 
I want to say that the medical profession 
as a whole has not since 1920 taken in- 
terest. It is an obligation that is rightfully 
theirs. You have had a small coterie of 
men bearing the brunt of your work. I 
say that advisedly. I have attended every 
session of the Legislature since 1920 and 
I have seen practically the same men every 
year defending attacks made upon your 
Medical Practice Act. I have heard men 
say that merely by manipulation of the 
spine they could cure diphtheria, scarlet 
fever, syphilis, and cancer. Hereby by the 
manipulation of the spine they could be 
done away with. It is ridiculous to think 
that these things can be done, but it would 
not be so ridiculous if you would stand up 
there and hear these people, just as earnest 
apparently, just as sincere as we are in 
this room at this time, believing these very 
doctrines. It would not make very much 
difference if someone got on the corner of 
Canal and Royal and preached doctrines of 
that kind, but when you see your legisla- 
tors believing these things and advocating 
these practices then I say that you have the 
obligation upon everyone of you to not 
leave that battle to a handful of men 
to carry on; and that is what has been 
done. You cannot expect the State Board 
of Medical Examiners to take any part as 
the State Board of Medical Examiners in 
that fight. They are placed there by the 
law to administer the law. The duty of 
defending that law rests upon the medical 
practitioners and rests upon the Medical 
Society to see that only trained men, 
capable of understanding the ravages of 
diseases now prevalent, are permitted to 
deal with the public. And you leave that 
fight up to a Committee of one or two. It 
is not fair to the mere handful who go up 
there time and time again. That obliga- 
tion is yours. I remember well in 1922 
when I was in the Attorney General’s office, 
that there were only four men who paid 
any attention to the attacks being made. 
There, later, got to be as many as twelve. 
But now I want to tell you that unless all 
of you make a determined effort to stamp 


out once and for all the attacks that are 
being made, that you can expect quackery, 
fakery of every kind, even the practice of 
attempting to relieve undr the cover of 
religion — I am not talking of any real 
religion, as I pay only respect to some of 
them, but I say under cover of religion, 
for there are people who are ready to rush 
to Louisiana believing it a Mecca. I be- 
lieve the time has come when you must 
maintain your position now or you will not 
be able to resist in future years onslaughts 
from other States 

As a parting word, I wish to impress 
upon you, the Society can begin in a no 
more useful way, nor in a better way than 
by advocating a minimum requirement for 
medical proctice throughout the United 
States, by having Congress adopt a law 
requiring a minimum for physicians 
throughout the entire United States. The 
requirements in some of the other States 
are lower than in this State. Unless you 
do this, you will rue it and the public will 
pay the price for having reposed this con- 
fidence in you. 


A STUDY OF TUBERCULOUS ADEN- 
ITIS CONFINED TO THE IN- 
GUINAL LYMPH GLANDS. 

EDWARD McCORMAC, M. D.f 
New Orleans. 

Tuberculosis not infrequently attacks the 
lymphatic system. The greater percentage 
of occurrences are seen, however, in the 
cervical glands. While it is not rare to see 
an involvement of the inguinal lymph 
g’ands, it is the opinion of the writer that 
the number of such cases is over-estimated. 
This source of error is to be found in the 
fact that a routine microscopic section is 
not done on all glands removed. In search- 
ing for literature upon this subject, 
directly, I was unsuccessful; not a single 
publication was obtainable. Text-books of 
pathology make mention of the condition 
being rare and say no more. 

fFrom the Urological Department, Tulane Med- 
ical School of Louisiana. 


16 


McCormac — A Study of Tuberculous Adenitis 


There have been some unusual and in- 
teresting malignant conditions of the in- 
guinal glands reported. The prevalence of 
adentitis as a secondary infection resulting 
from penile sores and uncleanliness is 
thoroughly understood. The type of case 
most interesting and presenting the hardest 
problem for diagnosis, is that in which the 
glands enlarge slowly, are sometimes 
slightly suggestive of fluctuation but fail 
to resolve and present varying degrees of 
pain. 

The cases herein reported are all taken 
from the wards in the Charity Hospital. 
A series of 2189 case histories of surgical 
tuberculosis have been reviewed. This in- 
cludes all types of tuberculosis requiring 
drainage or removal of the involved parts. 
A fair number of cases, probably forty or 
fifty, were diagnosed clinically as tubercu- 
losis. These were not included since con- 
firmation of the diagnosis was lacking. 
Fifty-two cases in which the microscopical 
report was tuberculosis have been included 
in the following table. All of these were 
clean-cut cases with the process involving 
the inguinal glands. Of these fifty-two, 
thirty-one were primary in the inguinal 
glands. Eight cases showed a tuberculous 
involvement elsewhere, six being in the 
lung, one being a general adenopathy plus 
a pulmonary tuberculosis, and one an in- 
volvement of the epitrochlear glands. In 
twelve cases the records failed to mention 
whether there was any involvement else- 
where or not. 

In forty-one cases the condition was 
unilateral, four bilateral, in six cases un- 
recorded, and in one no operative proce- 
dure was carried out. In the case not 
operated on, the patient had pulmonary 
tuberculosis with a general adenopathy 
and a clinical diagnosis was made of 
tuberculous inguinal adenitis. In two of 
this series adenitis developed following 
trauma. 

In twenty of the original fifty-two, the 
correct diagnosis was made. The remain- 


ing thirty-two were diagnosed variously, 
as suppurative adenitis, inflammatory aden- 
itis, and one case was called malignancy. 

In the original series of fifty-two cases, 
twenty-three were white, eighteen colored, 
and eleven unrecorded. 

There were forty-one males, four 
females, and in seven the history failed 
to record the sex. 

Twelve were not painful, twenty were 
painful, ten were slightly painful, and in 
the remaining ten this symptom was net 
recorded. 

Convalescence in all cases was unevent- 
ful. The time in the hospital varied from 
one to six weeks. In only one case was 
there a recurrence, and this was after a 
period of ten months. 

The percentage of adenitis being caused 
from venereal disease, of course, greatly 
out-numbers that of any other source. 
This is borne out by the fact that from 
the years 11906 to 1912, 1312 cases of bubo 
of venereal origin were operated in the 
Charity Hospital. The proportion between 
white and black was very small, 740 being 
black and 572 being white. 

CONCLUSIONS. 

1. The number of cases of primary 
tuberculous inguinal adenitis is distinctly 
over-estimated. 

2. In the so-called cases of idiopathic 
inguinal adenitis, the possibility of primary 
tuberculosis should always be considered. 

3. In cases of adenitis where the glands 
fail to suppurate or resolve, it is not un- 
wise to consider an early adenectomy 
because in a certain percentage of cases we 
are here dealing with an incipient tuber- 
culous condition. 

4. After the removal of the tuberculous 
glands the convalescence can be greatly 
aided by the application of radium follow- 
ing a complete adenectomy. 


McCormac — A Study of Tuberculous Adenitis 


17 


History 

Number 

Pre-operative 

Diagnosis 

TB Else- 
where 

Conva- 

lescence 

Recurrence 

Post-op. 

Diag. 

Microscop. 

Pain 

Age 

Sex 

Side 

Color 

837 



Uneventful 
16 days 

TB adenitis 

Slight 

16 

Male 

Unilateral 

Colored 

686 


No 

Operated 
7/4-8/2 
Disch. 8/29 

TB adenitis 


20 

Male 

Unilateral 

Colo r ed 

574 



Uneventful 
one month 

TB adenitis 

Present 

27 

Male 

Unilateral 

White 

548 

- 


Uneventful 
five weeks 

TB adenitis 

None 

38 

Male 

Unilateral 

White 

250 



Uneventful 
three weeks 

TB adenitis 

Present 

19 

Male 

Unilateral 

White 

260 



Uneventful 
25 days 

TB adenitis 

Present 

68 

Male 

Unilateral 

Colored 

261 


No 

Recovered 
Op. 10 mos. 
previous 

TB adenitis 


23 

Male 

Unilateral 

White 

262 



Uneventful 
one month 

TB adenitis 

Slight 

27 

Male 

Unilateral 

White 

286 



Uneventful 
six weeks 

TB adenitis 

Present 

17 

Male 

Unilateral 

White 

303 

Inguinal adenitis 

No 

Uneventful 
three weeks 

TB adenitis 

Present 

26 

Male 

Unilateral 

White 

322 


Pulmonary 

Uneventful 
three weeks 

TB adenitis 

Present 

24 

Male 

Unilateral 

Colored 

1102 

Inguinal adenitis.... 



TB adenitis 

Present 

24 

Male 

Unilateral 

White 




1116 

Inguinal adenitis 


Uneventful 
six weeks 

TB adenitis 


28 

Male 

Bilateral 

White 

1117 

TB ing. adenitis. 

(Sup.) 


Uneventful 
three weeks 

TB adenitis 


23 

Female 

Unilateral 

Colored 

1120 

Inguinal adenitis 

No 

Uneventful 
25 days 

TB adenitis 

No 

30 

Male 

Blow in 
groin 
shortly 
before 
Unilateral 

White 

1151 

TB adenitis.- 

No 

Uneventful 
seven weeks 

TB adenitis 

No 

38 

Male 

Unilateral 

Colored 

1154 

Sup. Inguinal adenitis 


Uneventful 
16 days 

TB adenitis 


22 

Male 

Bilateral 

Colored 

1164 

Sup. Inguinal adenitis 

No 

Uneventful 
two weeks 

Glands 
TB adenitis 

incised 4 
Slight 

mo 

36 

nths befo 
Male 

re following 
Unilateral 

soft sore 
White 

1169 

Sup. Inguinal adenitis 

No 

Uneventful 
three weeks 

TB adenitis 

Present 

48 

Male 

Unilateral 

White 

1013 

Sup. TB adenitis 

Pulmonary 

Uneventful 
17 days 

TB adenitis 


28 

Male 

Unilateral 

Colored 

1038 

TB adenitis...- 


Uneventful 
24 days 

TB adenitis 

Slight 

18 

Male 

Unilateral 

White 

1047 

Malignant adenitis..... 

No 

Uneventful 
six weeks 

TB adenitis 

Present 

29 

Male 

Unilateral 

White 


18 


McCormac — A Study of Tuberculous Adenitis 


History 

Number 

Pre-operative 

Diagnosis 

TB Else- 
where 

Conva- 

lescence 

Recurrence 

Post-op. 

Diag. 

Microscop. 

Pain 

Age 

Sex 

Side 

Color 

946 

Simple adenitis. 

No 

Uneventful 
eight days 

TB adenitis 

Present 

24 

Male 

Unilateral 

White 

963 

Sup. inguinal adenitis 

No 

Uneventful 
one month 

TB adenitis 


24 

Male 

Unilateral 

Colored 

B6556 (1307) 

Inguinal adenitis 

No 

Uneventful 
16 days 

TB adenitis 

No 

33 

Male 

Unilateral 

Colored 

C1610 (1320) 

Inguinal adenitis 

No 

Uneventful 
two weeks 

TB adenitis 

Present 





C2483 (1323) 

TB. inguinal adenitis 


Uneventful 
two weeks 

TB adenitis 


17 

Male 

Unilateral 

Colored 

C2760 (1324) 

Bilat. ing. adenitis 

No 

Uneventful 
nine days 

TB adenitis 


32 

Male 

Unilateral 

Colored 

C2526 (1328) 

TB inguinal adenitis 

No 

Uneventful 
two weeks 

TB adenitis 

Present 

47 

Male 

Unilateral 

White 

1337 

Inguinal adenitis 

No 

Uneventful 
10 days 

TB adenitis 

Present 

27 

Male 

Unilateral 

White 

1360 

Inguinal adenitis 

No 

Uneventful 
two weeks 

TB adenitis 

None 

19 

Male 

Unilateral 

Colored 

1380 

TB inguinal adenitis 

No 

Uneventful 
18 days 

TB adenitis 

Present 

28 

Male 

Uni. op. 
for hernia 
and gland 
removed 
TB 

White 

1196 

Inguinal adenitis 

(Sup) 

No 

Uneventful 
one month 

TB adenitis 

Present 

20 

Male 

Unilateral 


1211 

Inguinal adenitis 

Pulmonary 

? 

Uneventful 
19 days 

TB adenitis 

None 

30 

Male 

Unilateral 


1213 

Inguinal adenitis 

No 

Uneventful 
4 weeks 

TB adenitis 

Slight 

25 

Male 

Unilateral 


1229 

Inguinal adenitis 

No 

Uneventful 
11 days 

TB adenitis 

Present 

40 

Female 

Unilateral 


1244 

Inguinal adenitis 

No 

Uneventful 
20 days 

TB adenitis 

None 

36 

Male 

Unilateral 

White 

1257 

Inguinal adenitis 

(Sup) 

No 

Uneventful 
9 days 

TB adenitis 


26 

Male 

Unilateral 

White 

B09950 

Sup. inguinal adenitis 

No 

Uneventful 
one week 

TB adenitis 

Slight 





C03867 

Sup. inguinal adenitis 

No 

Uneventful 
three weeks 

Operated for 
TB adenitis 

right in 
Present 

g. he 

rnia 6 mo 

s. previous 


B03821 

TB adenitis. 

Pulmonary 
and gen. 
adenitis 

Discharged 

TB adenitis 

None 



No 

operation 


A161 (1846) 

TB 

No 

Uneventful 
22 days 

TB adenitis 

None 

47 

Male 

Uni. 

following 
injury to 
toe 6 weeks 
previous 

Colored 

1553 

TB inguinal adenitis 

Epitroch. 
TB adenitis 

Uneventful 
six weeks 

TB adenitis 

None 

42 

Female 

Bilat. and 
right elbow 

Colored 


May — Constitutional Psychopathic Inferiority 


19 


History 

Number 

Pre-operative 

Diagnosis 

TB Else- 
where 

Conva- 

lescence 

Recurrence 

PoST-OP. 

Diag. 

Microscop. 

Pain 

Age 

Sex 

Side 

Color 

1561 

Inguinal adenitis 

Pulmonary 

Uneventful 
two weeks 

TB adenitis 


20 

Male 

Unilateral 

White 

1407 

Chancroid adenitis 

No 

Uneventful 
one week 

TB adenitis 

Present 

20 

Male 

Unilateral 

Colored 

1567 

TB inguinal adenitis 

No 

Uneventful 
three weeks 

TB adenitis 

Slight 





1412 

Inflam. ing. adenitis 

Pulmonary 

? 

Uneventful 
12 days 

TB adenitis 

Tender 





1423 

TB inguinal adenitis 

Pulmonary 

? 

Uneventful 
8 days 

TB adenitis 


21 

Male 

Bilateral 

White 

E2057 (1460) 

Inguinal adenitis 

No 

Uneventful 
two weeks 

TB adenitis 












B4840 (1297) 

Sup. ing. adenitis 

No 

Uneventful 
four weeks 

TB adenitis 

Present 

30 

Male 

Unilateral 

Colored 

1300 

Inguinal adenitis 

No 

Uneventful 
three weeks 

TB adenitis 

Present 

35 

Male 

Unilateral 

White 

1305 

Sup. ing. adenitis 

No 

Uneventful 
two weeks 

TB adenitis 

Present 

49 

Female 

Unilateral 

Colored 


CONSTITUTIONAL PSYCHOPATHIC 
INFERIORITY.* 

CLARENCE P. MAY, M. D.,f 
Jackson, La. 

“Constitutional inferiority” was intro- 
duced into American psychiatric terminol- 
ogy by Adolf Meyer in 1904. In 1913 M. J. 
Karpas descri|bed “psychic constitutional 
inferiority” as the foundation of most, if 
not all, of the psychoses. Three years later 
he used the term “constitutional inferior- 
ity” and his earlier views were subjected 
to alteration. 

The terms constitutional psychopathic 
inferiority, constitutional inferiority, con- 
stitutional ,psy copath, constitutional psy- 
chopathic state, and psychopathic personal- 
ity are usually used synonymously. An at- 
tempt to differentiate between constitu- 
tional psychopathic state and constitutional 
inferiority was made by Visher, who be- 


*Read before the Bi-Parish (E. and W. Feli- 
ciana) Medical Society, Jackson, La., October 12, 
1927. 

tClinical Director, East Louisiana State Hos- 
pital, Jackson, La. 


lieves that in the former there is usually 
no history of marked industrial inefficien- 
cy or anti-social conduct, and what gross 
maladaptation is present does not extend 
back to early life. Whether or not this dif- 
ferentiation is quite valid is questionable. 

Human behavior can only be effectively 
studied from the viewpoint that it is fun- 
damentally a problem of mind and charac- 
ter in relation to environment. Disordered 
behavior, then, must be chiefly a matter of 
disordered mind. 

In constitutional psychopathic inferior- 
ity we are dealing with a disorder of the 
constitution of the personality. It is not a 
matter of disease engrafted in a previously 
healthy individual, but rather with the 
gradual malformation of a character into 
an abnormal balancing of feelings in rela- 
tion to behavior. 

The difficulties are to be found in mal- 
formations of character, caused by an un- 
usual influence of emotional factors that 
have in some way failed to find adequate 
control through inhibitions, or to respond 
to counter-balances that we consider as es- 


20 


May — Constitutional Psychopathic Inferiority 


sential for normal life. The effects of these 
are to produce a class of individuals, who 
are not insane in a sense, but yet are not 
normal. Individuals of this class find it 
difficult to adjust themselves to family life 
and social relationships. These lead them 
to conflicts with laws, and they become so- 
cial failures that must be given special con- 
sideration. While the group of constitu- 
tional psychopathic inferiorities has charac- 
teristic features that are common to all, 
some observers believe that there are cer- 
tain manifestations, which stand out with 
such prominence, as to give them special 
significance. In some the abnormal quali- 
ties show as emotional instability with a 
tendency to outbursts of excitement, and 
disordered behavior that occurs under even 
trivial annoyances. In others the individ- 
ual is weak in wil land unable to adhere to 
any sustained plans, and is easily led into 
acts that bring him into social difficulties. 
In still another type the abnormalities lie 
in an instability of character, and a marked 
prominence of the imagination, which leads 
to a pathologic type of lying and acts of 
deceit. 

Kraepelin classifies constitutional psy- 
chopathic inferiority under seven headings : 
(a) the excitable; (b) the inadequate; (c) 
the impulsive; (d) the eccentric; (e) the 
pathologic liars and swindlers ; (f ) the anti- 
social; (g) the quarrelsome. 

His description of these types shows that 
certain principal features are repeated suf- 
ficiently frequently to allow classification 
into types, but it is to be remembered that 
psychopathy is a uniform conception, only 
in that it embraces psychic deviations from 
the normal that are not limited in any other 
way, and it is best not to say that psycho- 
paths have this or that quality, for accord- 
ing to the nature of the condition they can 
not have any definite limitations and there 
are no symptoms which are common to all. 
Every individual is a rule unto himself. The 
manifestations show an infinite Shading 
of variety, transition and combination. In 
most cases the affective peculiarities are 


in the foreground. If there is average or 
great intelligence, it has little regulating 
influence on the individtial’s actions. 

In the following table, J. H. Huddleson 
gives an interesting and valuable classifi- 
cation, with the incidence rates of twenty- 
one important characteristics, of constitu- 
tional psychopathic inferiority (see table). 

In a number of instances I have used 
this table in checking up manifestations 
in cases of constitutional psychopathic in- 
feriority, and have been pleased with the 
results obtained. Ordinarily, the constitu- 
tional psychopath is easily differentiated 
from the normal, but to group all individ- 
uals of psychopathic constitution in spe- 
cific types is neither easy nor satisfactory. 
Psychopathic traits occur in such intermix- 
tures in varying prominence of this or that 
abnormality that the feasibility of too rigid 
and extensive classifying becomes doubtful. 
While it is convenient for those dealing 
with problems of behavior in social rela- 
tions it presents clinical and psychologic 
difficulties. The psychopathic personality 
is a serious disturbing influence in the home 
and community, and his frequent conflicts 
with the law show his incapacity to adjust 
himself adequately to the regulations under 
which we all must live, making it necessary 
that his constitutional weakness be appre- 
ciated by those who administer laws or deal 
with problems of behavior. 

To what degree of intensity one wishes 
to designate the psychopath as sick, is ar- 
bitrary. From what degree one no longer 
wishes to consider him as a psychopath, but 
as insane, is discretionary. 

Bleuler says “many psychopaths are only 
in the social sense “not insane” ; before the 
forum of natural science, they suffer from 
the same anomalies as many insane only in 
a slighter degree; they are paranoid, schi- 
zoid, latent epileptics, cyclothymic, etc.” 

As the many anomalies of character are 
normal or usual to the individual they can 
not properly be said to constitute a psycho- 
sis, but as they lead to inefficient types of 


May — Constitutional Psychopathic Inferiority 


21 


INCIDENCE 




in 

in 



Number 

Each 

Classes of 


of 

100 

Characteristics 

Characteristics 

Cases 

Cases 

Physical manifestations: 

a Anatomic stigmas 

40 

.... 8 


*b Sexual anomalies 

. 21 

4 


c Enuresis (after age 5) 

„ 11..... 

2 


d Onychophagia (nail biting) 

.. 12 

2.5 


e Stuttering and stammering..... 

.. 46... 

9 

Addictions : 

f Drug addiction 

. 8 

1.5 


g Alcohol addiction 

.. 50 

10 


h Tobacco addiction 

11 

.... 2 

Traits suggesting manic- 




depressive make-up: 

i Emotional instability 

..318..... 

63.5 

Traits suggesting manic 




and paranoid tendencies: 

j Grandiosity and excessive self-esteem.....*. 

..102 

20.5 

Traits suggesting paranoid 




trend : 

*k Paranoid personality 

.. 90 

......18 

Traits suggesting schizo- 




phrenic make-up: 

*1 Metatopomania (tendency to wander from 




place to place) 

... 97 

.......19.5 


m Polypraxia (tendency to go from place of 




emplo 3 rment or job to another) 

.240 

48 


n Working beneath mental capacity.... 

.. 9 

2 

Traits suggesting mental 




deficiency: 

*o Poor cooperation and refractoriness 

...179 

36 


*p Unreliability (other than q and r) 

...157 

31.6 


*q Conscious exaggeration of symptoms 

..207 

41.5 

Conduct disorders: 

*r Malingering (charged as such) 

... 28 

5.5 


Malingering suspected 

.. 11 

2 


*s Truancy and A W 0 L tendency. 

... 74 

15 


*t Trouble making 

.. 95 

19 


*u All conduct disorders 

..250 

50 


One finding of a given trait conditions a single entry, except for traits marked with the asterisk. 
The counting of a trait in one of these starred groups may be duplicated in another starred group; 
that is, such groups overlap. 

Data in above table obtained in a study of five hundred cases. 


adjustment of the individual to his environ- 
ment, and as persons exhibiting these pe- 
culiarities often become actively disordered, 
they may be regarded as borderland condi- 
tions. The life of the individual is, to use 
the words of Regis, “one long contradiction 
between the apparent wealth of means and 
poverty of results.” 

It is my belief that, from a practical view- 
point, insanity means social incapacity. 

In the treatment of the psychopathic in- 
dividual, it is important to recognize ten- 
dencies and abnormalities as early as pos- 
sible in the life of the individual, and this 
is often possible in the earlier years of life 


or even in infancy, as the “nervous” man- 
ifestations of childhood are common traits 
that stand in intimate relation to the de- 
velopment of a psychopathic character. 
The physician has special responsibility in 
this period ; he should know how to distin- 
guish abnormal qualities, and be able to 
instruct parents in methods of dealing in- 
telligently with them. 

Whatever is impairing the health of the 
individual should receive careful attention. 
Training of the psychopathic child should 
be directed toward securing simplicity of 
life, quiet surroundings, and self restraint. 
The environment should be such as to make 


22 


Bayon — The Association of Quinidin Sulphate and Digitalis 


life as free as possible from all that pro- 
duces unusual stimulation. Early interest 
in sex matters should be guarded against 
as these always have relations that bring 
to the individual excessive emotional 
stresses, and are powerful influences in 
shaping character. 

In the adult, effort must be directed to- 
ward securing as good physical health as 
possible. Environment should be chosen 
with an appreciatioh of the limited and spe- 
cial capacities for adjustments that are 
characteristic of the psychopath. The in- 
dividual must be taught to exercise self 
control, and to govern his life with an intel- 
ligent understanding of those influences 
that he cannot adequately handle. These 
principles are theoretical, and too often 
bring no improvement, and the individual 
continues a social menace. In these in- 
stances, it is best for the protection of so- 
ciety that the psychopath, who possesses 
criminal tendencies, be confined in institu- 
tions for the mentally abnormal, reforma- 
tories or prisons. Judges should appreciate 
the limited capacities that the psychopathic 
criminal has for controlling his behavior 
and that psychopaths form a large propor- 
tion of repeated offenders. Determination 
of penalties should be largely determined 
by the mental constitution of the offender, 
which is often such as to make long periods 
of confinement advisable. 

REFERENCES 

1. Barrett, A. M.: Psychopathic personality. Pamphlet. 

No date. 

2. Bleuler, E. : Textbook of psychiatry. N. Y. Mac- 

millan Co. 1924, p. 569-71. 

3. Huddleson, J. H. : Connotation of Constitutional 

Physchopathic Inferiority without Psychosis. J. A. M. A. 
86:1960-63, 1926. 

4. White, W. A. : Outlines of psychiatry. Washington, 
New & Ment. Dls. Pub. Co. 1923, p. 294-97. 


THE ASSOCIATION OF QUINIDIN 
SULPHATE and DIGITALIS IN 
AURICULAR FIBRILLATION. 

HENRY BAYON, M. D., 

New Orleans. 

The introduction of quinidin in the treat- 
ment of cardiac disease marks a compara- 
tively recent innovation in therapeutics, 
rivalling in its effects the many spectacular 
occurrances of modern medicine, holding 
attention, commanding inquiry, and unfor- 
tunately spurring on to reckless exaggera- 
tion many who, eager to go farther for- 
wards, are lured into the pitfalls of dan- 
gerous experiment. 

The history of quinidin and of quinin, its 
sister alkaloid, is not lacking in interest, 
very much like that of their physiologic 
antithesis, digitalis; all at one time were 
the property of empiricism. It is common 
knowledge that digitalis, previous to the 
careful attention given to it by Withering 
in 1874, was the principal ingredient of a 
mixture used by an old woman healer who 
was said to have restored to health a num- 
ber of cases of dropsy. On the other hand 
it seems that quinin, for a great many years 
past, has been employed in the treatment 
of heart disease. A number of physicians 
of the old school favored the combination 
of the two drugs: Weckenbach^^®) re- 

calls that Ludwig Traub habitually com- 
bined them so as to avoid the disagreeable 
effects of digitalis on the stomach. Op- 
palzer reckoned quinin, rest and digitalis as 
our three most powerful therapeutic re- 
sources in diseases of the heart; Stokvis 
points to the fact that quinin, owing to its 
damping of an excessive digitalis action, 
may in many respects be called an antag- 
onist to digitalis; Pil always gave digitalis 
and quinin together because he found that 
the mixture had a better effect on his pa- 
tients than digitalis alone. Huchard fa- 
vored quinin in the treatment of paroxys- 


*Read before the Orleans Parish Medical 
Society, December 12, 1917. 


Baton — The Association of Quinidin Sulphate and Digitalis 


23 


mal tachycardia and other arrythmias, 
either alone or associated with digitalis. 

It is surprising that during a period when 
so little was known regarding the pharma- 
cology of quinin and digitalis, and when 
the chief guiding spirit in the choice of 
drugs was sound and acurate observation, 
in a large measure, unaided, by extensive 
experimental work, so much of the value 
and interdependence of the two drugs 
should have been recognized: digitalis, as 
we now know by its action on the vagus, 
stimulating cardiac inhibition, and quinin 
depressing it. Cheinisse^^) quotes the ex- 
periments of Stokvis on the isolated heart 
of the frog: in 1905, that investigator de- 
monstrated that digitalis increases the 
number and intensity of the pulsations, 
lengthening systole and exciting the heart, 
whereas quinin diminishes both the num- 
ber and force of the contractions and 
shortens systole. He affirmed that quinin 
favored the action of digitalis and that the 
combination of both drugs yielded thera- 
peutic results which were far more satis- 
factory than those obtained by the use of 
digitalis alone. Others using a combina- 
tion of both drugs found that the depress- 
ing action of quinin was prevented and that 
the exciting effect of digitalis was tem- 
pered; the results were an improvement in 
the cardiac activity. 

Pezzi and Clerc^^^) in France, report 
that dogs thoroughly quininized and receiv- 
ing massive doses of crystallized digitalein 
Niativelle failed to develop toxic symptoms. 
Experimenting on the isolated heart of the 
frog, Weichman, assistant of Von Romberg 
in Munich, has demonstrated this antago- 
nism of the two drugs. The experi- 
ments consisted in allowing the heart to re^ 
main in a solution of quinin until it ceased 
to beat, the paralysed organ was then im- 
mersed in a solution of digitalein which 
had the effect of restoring it to active con- 
tractions. 

Similar antagonisms between digitalis 
and quinin are also observed on the myo- 
cardium and on the conducting tissues : On 


the myocardium digitalis shortens the re- 
fractory period of the auricle, quinidin 
lengthens it. Digitalis speeds the auricu- 
lar rate, quinidin slows it, whereas quite 
the opposite effect is noticed on the ven- 
tricle which is slowed by digitalis and 
speeded by quinidin. The report of T. S. 
Hart^^> demonstrates the clinieal antagon- 
ism of the two drugs on the auricular and 
ventricular musculature by electro-cardio- 
graphic tracings of his patients. On the 
conducting tissues, the action of digitalis 
is stimulatng, that of quinidin is depress- 
ing, as evidenced by the P. R. interval which 
is shortened by digitalis, and lengthened by 
quinidin. 

Evidence of the physiologic antagonism 
between digitalis and quinidin, on the heart, 
both on the isolated myocardium and on the 
inhibition mechanism, is clearly demon- 
strated and the observations of old clin- 
icians regarding the advantage of the re- 
ciprocal relations of the two drugs on each 
other receive sanction in the light of modern 
scientific analysis. It is on this principle 
that quinidin therapy is founded. 

The effect of quinin in overcoming cer- 
tain hearft disturbances waS accidentally 
revealed to Weckenbach,^^'^^ in 1912, by 
a patient, a man of fifty years of age, who 
was annoyed by frequent attacks of very 
troublesome palpitations lasting from two 
to fourteen days, and who sought medi- 
cal advice in the hope of securing 
permanent relief. He boasted of being 
able to abolish the individual attacks very 
promptly and as that statement was ques- 
tioned, he promised to call back the next 
day with a regular pulse. True to his 
promise, and much to the surprise of the 
doctor, on the following day the pronounced 
arrythmia had completely disappeared; 
the patient had taken quinin, which, in lo- 
calities where malaria was prevalent, en- 
joyed universal favor throughout the whole 
range of disease. He had found complete 
relief from his cardiac distress twenty to 
twenty-five minutes after taking the drug 
and after a little experimenting, had dis- 


24 


Bayon — The Association of Qidnidin Sulphate and Digitalis 


covered that one gram would invariably put 
an end to the attack. Weckenbach was so 
impressed that he determined to try quinin 
in auricular fibrillation and in other condi- 
tions of hyperactivity of the heart, such as 
hyperthyroidism and exophthlamic goiter, 
in 0.5 to 0.8 gram doses. In the latter con- 
ditions the results were fairly gratifying, 
but in auricular fibrillation he had little or 
no success. 

It was left to Von Frey, in experimenting 
with other alkaloids of cinchona, to discover 
the much more effective and remarkable 
effects of quinidin especially in auricular 
fibrillation, the first publication of which 
appeared in 1917. Since lhat time numer- 
ous reports have appeared in nearly all 
parts of the civilized world with alternate 
waves of condemnation and exultant ap- 
probation. 

R. L. Levy<®^ gives an excellent sketch 
of the history of quinidin in which the fol- 
lowing facts are recorded: Quinidin was 

isolated by Heihningen in 1849 from a by- 
product in the preparation of quinin called 
chinoidin. Later, Pasteur prepared it in 
purer form and gave it the name of chini- 
din. It has also been known subsequently 
by other chemists as conchinin, cinchotin 
and beta-chinidin, and used extensively in 
the treatment of malarial fevers. Wunder- 
lich, in 1856, was the first to use it exten- 
sively in malaria, reporting one hundred 
cases in which he found it fully as service- 
able as quinin, giving it preference over 
quinin in hospital practice because cheaper. 
The dose was the same as quinin, ranging 
from 10 to 25 grains. In 1878, Strumpell 
used it for its antipyritic action in fifty 
cases of infectious disease. He reports one 
death, a typhoid patient who by mistake 
swallowed 4 grams in solution. In 1880, 
Freidenberger reported two deaths in 
children with scarlatina, vomiting, collapse, 
convulsions and death following a few 
minutes after the last dose. In the same re- 
view appears the case of a boy seven and 
a half years old which is instructive in so 
far as it demonstrates the toxic effects of 


quinidin in the presence of marked idiosyn- 
crasy. He received 12 grams in five days ; 
several times, vomiting followed the dose 
within one hour. On the fifth day edema 
and on the sixth day general anasarca ap- 
peared with diarrhea lasting two days, fol- 
lowed by profuse diuresis and disappear- 
ance of anascarca. Four days after dis- 
continuing the drug it was given again for 
one day on account of rise in temperature 
with the reappearance of the anasarca, 
which, as it did on the previous occasion, 
disappeared promptly after withholding 
treatment. As Levy observes, even at that 
time when extensively employed as an an- 
tipyretic, undesirable effects were attri- 
buted to its use. 

Since Von Frey’s discovery of the effects 
of quinidin in auricular fibrillation, the as- 
sociation of digitalis to quinidin in the treat- 
ment of that form of arrythmia has almost 
always been advocated. Differences, how- 
ever, loom up when methods are considered 
concerning the relative advantages of simul- 
taneous or alternate use of the two drugs. 
Preparatory digitalisation, especially when 
congestive heart failure appears in the case 
history, either present or not very remote, 
is without doubt the method of choice as ad- 
vocated by Frey, and followed by the ma- 
jority. In France, Cheinisse*^) claims pri- 
ority in introducing quinidin in the treat- 
ment of auricular fibrillation in that coun- 
try, associating digitalis as a preliminary 
measure in the presence of heart failure. 
Clerc and Pezzi, Josue, Lian and Vasquez 
advocate the same method — Lecompte urges 
the combination of ouabain and digitalis. 
Deschamps, still more drastic, advocates 
digitalis before quinidin, even in the ab- 
sence of cardiac failure. In the presence 
of heart failure he leans to ouabain which 
he combines with digitalis. He cites one 
case brilliantly relieved by preliminary 
digitalisation, reenforced by intravenous in- 
jection of ouabain. In Germany, Von 
Romberg, Von Kapt and others adopt the 
same principles. Others favor the alter- 
nate treatment but reverse the order — ^Von 
Bergman in Germany, Hewlett and 


Baton — The. Association of Quinidin Sulphate and Digitalis 


25 


Sweeney/ Hamburger and Priest in 
America, prefer quinidin at once without 
previous digitalisation, their objection to 
digitalis is that the relief from fibrillation 
is retarded on account of the increase in 
auricular rate caused by digitalis and that 
larger doses of quinidin are required. Ham- 
berger and Priest seem to credit digitalis 
with failure to restore normal rhythm or 
to cause it to be of short duration. But, as 
observed by Lewis, who, although ad- 
mitting this action of digitalis and even 
that the fall in the auricular rate is some- 
times not quite so marked when the heart 
has been previously digitalised, and indeed 
may be delayed thereby, claims for it the 
advantage of reducing the ventricular rate 
which fibrillation keys at dangerous levels ; 
for this reason he advises the simultaneous 
use of both drugs, “digitalis controlling the 
ventricular rate throughout the quinidin 
reaction”. 

Preparatory digitalisation before quini- 
din is now almost universally regarded as 
essential, especially when dealing with ad- 
vanced cardiac insufficiency, indeed even 
in the absence of well established organic 
disease it seems that the response to quini- 
din, if perhaps a little delayed, is more sat- 
isfactory when digitalis is used as a prepar- 
atory measure. 

There can be no plausible objection to the 
combined or alternate use of digitalis and 
quinidin on the plea of antagonism of the 
two drugs to each other, any more than to 
the usual combination of morphia and 
atropin. The pharmacologic relations of 
the two combinations are in every way 
similar and in the light of reason as well 
as in that of actual observation, this an- 
tagonism, far from being harmful is a de- 
cided advantage. It would be just as il- 
logical to abstain from atropin in combina- 
tion with morphia because the former stim- 
ulates the respiratory center whereas the 
latter depresses it, as to object to the as- 
sociation of digitalis to quinidin because 
digitalis speeds the auricle and slows the 
ventricle, whereas quinidin does just the 


contrary. Atropin counters the ill effects 
of morphin without interfering with its 
sedative action, just as digitalis protects 
the heart against the excessive ventricular 
rate caused by quinidin without any appre- 
ciable obstacle to the return of normal 
rhythm. 

The protective influence of quinin against 
cardiac poisons and conditions inducing 
auricular fibrillation is well illustrated by 
the experiments of Pezzi and Clerc<i^> 
who, in 1920, accidentally observed an auri- 
cular fibrillation * produced spontaneously 
in a dog after opening its thoracic cavity 
and pericardium. The object of the experi- 
ment was to gauge the toxicity of quinin. 
The arrythmia had been in progress for 
forty-five minutes, when the animal was 
quininized, after which the arrythmia was 
suddenly followed by normal rhythm. Ex- 
tending their investigations regarding the 
effects of quinin in auricular fibrillation 
they observed that in dogs previously quin- 
inized, it was almost impossible to induce 
the arrythmia by faradisation and when 
fibrillation was induced, it was ephemeral 
and always very much less marked than in 
dogs not previously treated with quinin. 
The authors claim that these findings con- 
firm those of Hecht and Rothberger in 1919, 
who reported the uniform reduction of au- 
ricular fibrillation in dogs, by the intrave- 
nous injection of quinin sulphate. In ani- 
mals so treated, intense faradisation failed 
to cause auricular fibrillation. Pezzi and 
Clerc have also shown that nicotin, which 
invariably produces auricular fibrillation 
in dogs, has no such action when the animal 
has been previously quininized. They have 
had the same results with barium chlorid 
which fails to develop immediate fibrilla- 
tion of the auricle always following in dogs 
not previously treated with quinin. 

DOSAGE. 

The dose required to restore normal 
rhythm is variable, some patients re- 
sponding to small quantities. In consult- 
ing the literature on the subject it is not 
rare to find a number of cases in which 
fibrillation has promptly yielded to the trial 


26 


Bayon — The Association of Quinidin Sulphate and Digitalis 


dose of 3 grains, usually given to test the 
patient’s susceptibility. When this is found 
absent 5 to 10 grains, repeated 3 or 4 times 
a day, is the dose usually recommended ; 
the average dose is 4 to 7 grm. over a period 
of 5 days. John Hay reports that the aver- 
age dose recommended by English cardio- 
logists is 5 to 10 grains three times a day, 
sometimes increased in obstinate cases as 
far as 3 grams a day. A maintenance dose 
of 3 to 5 grains once or twice a day after 
restoration of normal meshanism and con- 
tinued indefinitely or with short periods of 
interruption, meets with widespread favor 
— Lian<i“* favors 20 c.gm. four or five times 
a day, continued for one week following the 
return of normal mechanism, then he pre- 
scribes alternately for 3 weeks, 20 c.gm. of 
quinidin for 5 days and 1/10 mg. of crystal- 
lized digitalein for five following days, 
completing the treatment by continuing for 
some time the alternate use of digitalis and 
quinidin, the patient taking 4 or 5 — 20 c.gm. 
doses of quinidin a day during the first five 
days of each fortnight, followed by 1/10 
mg. of crystallized digitalein a day during 
the first five days of the second week. Sir 
Thomas Lewis advises 0.2 to 0.4 grms. in 
divided doses, the allowance being from 1 
to 2 grms. a day. Some have carried the 
dose to impressionistic heights, apparently 
with no untoward results. Drew Luten<“> 
reports a refractory patient to whom in- 
creasing daily doses were given for 16 
days; on the 16th day he received 240 gr. 
in the 24 hours. Nothing happened except 
nausea and vomiting. A few days after- 
wards, he was discharged feeling quite well 
but still fibrillating. Nathan Sidell and 
Frederick G. Dorwart<^®> tabulate a num- 
ber of cases in which the dose was gradually 
increased to 75, 90 or even 200 grains in the 
twenty-four hours. Such huge dosage is 
interesting from the viewpoint of tolerance 
which some patients show to quinidin, 
even in a decidedly advanced stage of de- 
compensation, but it is questionable 
whether it were not to the patient’s better 
interests to give preference to more con- 
servative dosage or to repeated trials, al- 


lowing a period of rest between trials, 
rather than the display of such therapeutic 
virtuosity. 

The danger of clotting in the fibrillating 
auricle with the possible result of embolism 
which attends the restoration of normal 
rhythm has been at all times the principal 
objection to quinidin. Mackenzie rejects 
it on the plea that the danger of fibrillation 
is not so much the disturbed rhythm, as the 
exhaustion depending on the increased 
ventricular rate. He cites a case of auri- 
cular fibrillation<i2^ in a patient of seventy- 
five years of age who had been fibrillating 
for fifteen years without interruption and 
to whom he had refused treatment. 

Viko, Marvin and White<^®> have re- 
ported a number of cases of auricular fib- 
rillation, some treated with quinidin and 
others without it; the report purporting to 
prove that there is very little difference, if 
any, in the danger of embolism following 
quinidin therapy, compared with other 
methods of treatment. In a series of 484 
cases treated with quinidin, 15 developed 
embolism and in another group of 200 
cases treated without quinidin, embolism 
occurred in 16 cases. 

Robert Levy<®> presents a similar table 
on a smaller scale: in 50 cases of auricular 
fibrillation, 25 were treated with digitalis 
alone and 25 with digitalis and quinidin. 
Of the 25 cases treated with digitalis alone, 
five developed embolism and in the group 
treated with quinidin, only one suffered 
from embolism. 

John Hay<25) reports that at a meeting 
of the Cardaic Club in Edinburg in 1923, 
the value of quinidin in auricular fibrilla- 
tion was discussed. It was found that of 
286 cases including 265 of auricular fibrill- 
ation and 21 of paroxysmal tachycardia and 
auricular flutter, embolism occurred in 7 
cases only. 

There seems to be but little doubt that 
clotting in the auricles occurs more fre- 
quently during the prevalence of auricular 
fibrillation than when the rhythm is nor- 


Bayon — The Association of Quinidin Sulphate and Digitalis 


27 


mal. This has been demonstrated by 
Thomas Lewis<^^ who in 76 post-mortem 
examinations of patients dying of chronic 
heart disease in which clots were sought, 
found them in 8 cases out of 23 in which 
fibrillation was present in the last illness 
and in only 4 cases out of 53 in which the 
mechanism had been normal, but it did not 
appear to him that embolism due to the de- 
tachment of these clots was more common 
when fibrillation existed than when the 
rhythm was normal. It is evident that when 
there are clots in the auricles, the danger 
of embolism is ever present, whatever be the 
rhythm, normal or abnormal, but it is 
equally evident that such influences as 
emotion, effort or various forms of medica- 
tion are just as potent, if not more so, in 
causing embolism than the return of a fib- 
rillating auricle to sinus rhythm. In con- 
sideration of these facts, with due allow- 
ance for some possible doubt concerning the 
exact cause of death in some cases, and 
when the natural disposition to embolism 
in heart disease is considered, it is clear 
that the danger of embolism following 
quinidin has been much exaggerated. The 
evidence condemning quinidin will thercr 
fore always remain lame and inconclusive. 

Similar deductions apply regarding sud- 
den death not due to embolism. However, 
normal mechanism is usually followed by 
so much improvement in cardiac reserve 
with its attendant restoration to comfort- 
able and useful life, in contrast with the 
discomfort and invalidism of a quivering 
heart, that the risk of embolism or even 
sudden death is amply justified. 

However, it is well to remember that com- 
pensation is not always restored after the 
establishment of normal rhythm. Korns<’^> 
reports cases of patients who seemed 
totally indifferent to fibrillation or normal 
rhythm, or even to transitional mechanisms. 
He cites a patient, who, “while maintain- 
ing a normal rhythm under the influence 
of quinidin, suddenly developed auricular 
flutter with immediate doubling or trip- 
ling of the ventricular rate and where 


other changes occurred repeatedly without 
notice to the patient or modification of his 
condition. His subjective and objective 
signs seemed entirely independent of fibrill- 
ation, flutter or normal rhythm”. Such 
cases are exceptional. Regular rhythm, 
even though it be normal only from the 
standpoint of ventricular rhythm, regard- 
less of any deviation from sinus rhythm, is 
in some cases quite an advantage to the pa- 
tient as is shown in the report of Case No. 
1 appearing at the end of this paper. 

CONTRA-INDICATIONS 

Much disappointment and discredit to 
both the attendant as well as to quinidin 
can and should be avoided by the proper 
selection of cases. Thomas Lrewis claims 
never to have had a case of embolism fol- 
lowing quinidin, probably on account of his 
care in avoiding cases where it is contrain- 
dicated. The most important contraindica- 
tions are: 1. Advanced myocardial in- 

sufficiency. 2. Congestive heart failure, 
especially when associated with multiple 
valvular disease. 3. Fibrillation of long 
standing. 4. Idiosyncracy, or when early 
unpleasant symptoms accompany treatment 
and persist; in such cases normal mechan- 
ism is not likely to occur. 5. Palpitation 
or distressing increase in ventricular rate 
is apt to lead to ventricular tachycardia fol- 
lowed by ventricular fibrillation. However, 
tachycardia, if due to convertion of fibrilla- 
tion to flutter, is no indication to interrupt 
the treatment, provided there is no evi- 
dence of serious cardiac or circulatory 
unbalance. 6. A history of previous em- 
bolism. 7. Auricular fibrillation occurring 
with cessation of attacks of angina. 8. No 
response to digitalis. 

INDICATIONS 

1. When fibrillation is paroxysmal and 
occurring in undamaged or slightly damag- 
ed hearts, either from myocardial or valve 
disease. 2. When the cardiac upset dates 
from the beginning of fibrillation. 3. 
When fibrillation occurs during the course 
or follows an acute infection. 4. Lastly, 
in thyrotoxic cases especially when fibrilla- 


28 


Bayon — The Association of Quinidin Sulphate and Digitalis 


tion continues after successful treatment 
of thyroid conditions, either by surgical or 
medical treatment. 

Without disregarding the importance of 
discriminating between suitable and unsuit- 
able cases there are numerous instances 
where every contraindication to quinidin 
exists, such as badly damaged hearts, con- 
gestive heart failure, valvular lesions and 
fibrillation of many years’ duration, where 
notwithstanding, quinidin restores normal 
rhythm, alleviates suffering and prolongs 
life. In the report of Viko, Marvin and 
White it is shown that in 75 unselected 
cases, restoration occurred in 68 per cent 
of the cases. A higher rate of response to 
and maintenance of normal mechanism oc- 
curred in arterio-sclerotics than in rheu- 
matics, probably, the authors infer, on 
account of the greater frequency of conges- 
tive heart failure in rheumatics; undoubt- 
edly in such cases greater care should 
be observed and the danger signalled to 
the patient or to his relatives whose con- 
sent should be an important factor in de- 
ciding whether or not the treatment is to 
be tried. 

The two cases here presented are useful 
in so far as they demonstrate some inter- 
esting indications for quinidin and the 
phenomena apt to follow its use. 

Case I. Mrs. M. J., 68 years of age; history of 
arteriosclerosis 30 years duration ; had a labyrynthic 
hemorrhage about 26 years ago. Blood pressure 
200-240/110-120. Kidneys normal, last functional 
P-S-T test six months ago showed 68 per cent elim- 
ination. For the past 4 years she has had fre- 
quent attacks of edema of the lungs accompanied 
by auricular fibrillation which at first promptly 
yielded to digitalis. In July, 1925, however, fol- 
lowing an attack of edema of the lungs with its 
accompanying auricular fibrillation, cardiac failure 
■was relieved by digitalis, but fibrillation became 
permanent. After five or six weeks of continuous 
fibrillation, wie decided to hospitalise her and give 
her quinidin. The electrocardiogram confirmed 
the diagnosis. After thorough digitalisation: 25 
drops tine, digitalis 3 times a day for 3 days; a 
test dose of 3 grains of quinidin showing no idio- 
syncrasy, she was given 5 grains every 4 hours; 
after the 5th dose her pulse became regular with 
a rate of 70. Quinidin was continued in 5 gr. 


doses three times a day for one week and then 
discontinued. Since that time she has had fre- 
quent attacks of fibrillation ■with congestive heart 
failure which in some instances were quite acute, 
the lungs filling ■with rales. The attacks, some of 
which were in progress for several days, were uni- 
formly relieved by quinidin preceded by digitalis. 
Once in June, 1926, during one of her attacks of 
auricular fibrillation, as there were no signs of 
congestion of the lungs she was given 5 grains 
of quinidin every 4 hours without preparatory 
digitalisation, with no relief; quinidin was discon- 
tinued for a fewi days and digitalis given in 20 
drop doses every 4 hours until signs of digitali- 
sation appeared. Digitalis was then discontinued 
and quinidin given every 4 hours in 5 grain doses, 
with the appearance of a regular pulse of 70 per 
minute after the 4th dose. On February 25, 
1927, after an unusually severe attack, treatment 
was resumed with the same successful result; an 
electrocardiogram showed that although the pa- 
tient was very comfortable with a pulse regular 
in rhythm and rate, she had a decided right bundle 
branch block and the absence of the P wave in 
the three leads showed that the auricles were 
still fibrillating. On April 15, 1927, after recov- 
ering from an attack and with a regular pulse of 
70, the electrocardiogram showed marked im- 
provement in the branch block, an inconspicuous 
P wave appearing in the first two leads. Main- 
tenance doses of quinidin, 3 grain capsules, were 
prescribed twice a day in the attempt to abolish 
the recurring attacks, and for five weeks, the 
longest interval between attacks in the history of 
the case, the heart remained regular, but as the 
patient became nauseated, fearing that the treat- 
ment was responsible for upsetting her, and with- 
out consulting me, she discontinued quinidin; as 
a result, fibrillation recurred. She was again 
treated with digitalis and quinidin and as on previ- 
ous occasions, regular ventricular action followed 
the fourth 5 grain dose of quinidin, and to this 
day she has had no recurrence. She is still taking 
her two 3 grain maintenance doses of quinidin. 

Case II. Mrs. G., about 58 years of age, was 
seized on January 14, 1927, with ■violent palpita- 
tion and dyspnea in the effort to raise a door 
which had become unfastened from its hinges. 
She had enjoyed excellent health until a year be- 
fore her last illness when a carcinoma of the 
uterus was detected. Her general health how- 
over seemed not much altered. When seen, the 
heart which had never before given trouble, was 
totally irregular with a large pulse deficit, rales 
were present at the base of both lungs. Twenty-five 
drops of tr. of digitalis every 4 hours for 3 days re- 
lieved the pulmonary congestion, but the arryth- 
n.ia was unaffected ; digitalis was discontinued and 
5 grain quinidin capsules given every 4 hours. 
Complete relief followed the third dose. She was 


Bayon — The Association of Quinidin Sulphate and Digitalis 


29 


seen the following morning and instructed to 
remain absolutely quiet for a few days. Feeling 
so well and comfortable, she ignored the instruc- 
tions and walked to her kitchen to prepare her 
supper when she suddenly fell to the floor, dying 
instantly. 

In Case 1, the notable features are: 1. 

That auricular fibrillation may be present 
with a pulse normal in rhythm and rate. 
Mackenzie reports a similar case^^^) refer- 
ring him to Lewis for electrocardiographic 
tracings which revealed that the auricles 
were fibrillating, the patient’s pulse being 
regular. 2. The uniformity of results 
when quinidin was preceded by digitalis. 
We have not repeated the experiment of 
giving quinidin without preliminary digit- 
alisation in this case, after the one failure 
of quinidin, not preceded by digitalis. 3. 
The comfort and relief of the patient when 
the pulse rhythm and rate became normal, 
although distinct departure from sinus 
rhjd;hm appeared in the electrocardiogram. 
4. The remarkable effect of small mainten- 
ance doses of quinidin. 5. The brilliant 
results of quinidin when the origin of fibril- 
lation coincides with the first signs of 
cardiac upset. 

In Case II, as no post-mortem examina- 
tion was made, the cause of death remains 
obscure : cerebral embolism, or hemorrhage, 
or heart failure? The moral however, is 
the necessity of insisting on rest in bed for 
a few days after quinidin has regulated the 
pulse. 

BIBLIOGRAPHY 

1. Cheinisse, L. : Medicaments antagonistes a la quin- 

idine. Presse Med., 30:1113, 1922. 

2. Cheinisse, L. : Quinidine et digitale. Presse Med., 

30:734, 1922. 

3. Hamburger, W, W., & Priest, W. D. : Quinidin 

treatment of auricular fibrillation. J. A. M. A., 19:187, 
1922. 

4. Hart, T. S. : Quinidin in auricular fibrillation. Presse 

Med., 30:692, 1922. 

5. Hay, J. : Action of quinidin in the treatment of 

heart disease. Lancet, 2:643, 1924, 

G. Hewlett, A. W., & Sweeney, J. P. : Quinidin treat- 

ment of auricular fibrillation. J. A. M. A., 77:1793, 1921. 

7. Korns, H. M. : Experimental and clinical studies of 

quinidin. Arch. Int. Med., 31:36, 1923. 

8. Levy, R. L. : Clinical studies of quinidin. J. A. M. A., 
79:1108, 1922. 


9. Lewis, T. : Quinidin in auricular fibrillation. Am. J. 

M. Sc., 163:781, 1922. 

10. Lian, C. : Les resultats du Sulphate de Quinidine 

dans I’erythmic complete. Presse Med., 32:297, 1924. 

11. Luten, D. : Use of Quinidin in, auricular fibrillation. 

M. Clin. N. Amer., 9:227, 1926. 

12. Mackenzie, J. : Auricular fibrillation. Brit. M. J.. 

2:869, 1911. 

13. Mackenzie, J. : Quindin in auricular fibrillation. 

Brit. M. J., 2:576, 1921. 

14. Pezzi, C., & Clerc, A.: Action cardiaque de la 

quinidine. ses indications therapeutiques. Presse Med., 28: 
334, 1920. 

15. Sidell, N., & Dorwart, F. : Quinidin sulphate in auri- 

cular fibrillation. Boston M. & S. J., 196:216, 1927. 

16. Viko, L. E.. Marvin, H. M., & White, P. D. • Clini- 
cal report on the use of quinidin sulphate. Arch. Int. Med., 
31:345, 1923. 

17. Weckenbach, K. F. ; Cinchona derivatives in the 
treatment of heart disorders. J. A. M. A., 81:472, 1923. 

18. Wechenbach, K. F. : (Title not available.) Nederl. 

Tijdschr. v. Geneesk., 68:460, 1924. 

DISCUSSION 

Dr. A. E. Fossier: Dr. Bayon has so fully and 

so thoroughly covered his subject that it is very 
hard for me to discuss it. All that is left for me 
to do is to repeat some of the many good points he 
has given us. 

The first thing to be considered is the action of 
quinidin: Its auricular action is the restoration 

of sinus rhythm due to its power of increasing 
the refractory period of the auricular muscle 
fibers, this causes an abrupt termination of the 
circus movement, which is said to be the cause of 
fibrillation and auricular flutter. The P-R inter- 
val is often at first lengthened, but soon returns 
to normal. Besides, quinidin lowers the conduc- 
tion rate in the auricular fibers which results in 
a reduced number of fibrillations. As long as the 
fibrillations remain about 350 to 600 per minute, 
the rhythm is that of fibrillation; if they are less- 
ened, two things happen : first, sinus rhythm will 
be abruptly restored ; second, auricular flutter will 
take place. Once flutter is established, if quinidin 
is pushed it will terminate in sinus rhjrthm. 

The action of quinidin on the vagi is opposite 
to that of digitalis; digitalis increases vagal tone 
and diminishes ventricular rate; quinidin lowers 
vagal tone and increases ventricular rate. This 
increase of rate may be so great as to cause dis- 
continuance of the drug. Digitalis is given to 
prevent this possibility of its producing heart 
block. 

The absorption and elimination of quinidin are 
most important factors to consider. It is more 
rapidly absorbed and more quickly eliminated than 
digitalis. Auricular flutter may occur as early as 
two hours after the administration of quinidin. 


30 


Bayon — The Association of Quinidin Sulphate and Digitalis 


The elimination of quinidin is also very rapid. It 
usually disappears from the ui’ine within 12 to 24 
hours. It should be prescribed at shorter inter- 
vals, while digitalis should be given at longer 
intervals. 

I fully agree with Dr. Bayon that a good many 
of the deaths attributed to the use of quinidin 
may not be occasioned by the drug. The doctor 
has given us statistics which prove his contention 
tbat many of these cases which terminated fatally 
after the use of quinidin would have died if they 
had not taken quinidin. I know it has prevented 
a good many physicians from using quinidin when 
they could prescribe it with a large margin of 
safety. Of course, there are precautions to be ob- 
served. Quinidin is a cardiac and respiratory de- 
pressant. Sudden death and embolism may attend 
its use, attacks may occur; but this may happen 
under any other circumstances, therefore this 
should not mitigate against the proper use of 
quinidin. 

In the administration of this drug we must, 
as much as possible, select our cases. The stand- 
ard of selection I generally use are that the cir- 
culation must be efficient without the help of 
drug while the patient remains in bed, and there 
must not be any edema, albuminuria or enlarge- 
ment of the liver. Then quinidin may be given 
irrespective of the heart condition. Treatment 
should be inaugurated when patient is w'ell enough 
to be discharged, otherwise it must be employed 
with great caution. It is a dangerous drug in 
exhausted heart muscle. 

Now, the method of administering the drug. 
Frey’s method of administrating the drug is my 
choice. We give six grains in the morning; one 
dose of six grains the first day, two doses of six 
grains the second day, three doses of six grains 
the third day, until the maximum of ten doses of 
six grains are given in one day. The doses are 
to be repeated every two hours. The best time 
to begin the administration of the drug is early 
in the morning. The absorption and elimination 
of the drug is so rapid that in giving it at such 
short intervals it produces no ill effect. You can 
let your patient up a short while after he has been 
benefitted from the use of the remedy. 

I must also caution you to record frequently 
the rate and the volume of the pulse. The elec- 
trocardiograph should also be used in these cases 
frequently as a control. No rhythm is to be ac- 
cepted as sinus rhythm unless it is confirmed by 
electrocardiograms. Once sinus rhythm is estab- 
lished, the drug is to be discontinued. In the 
more severe cases we have got to go most care- 
fully. Occasionally we are never able to bring 
our cases down to the ideal standard. 

I wish to emphasize what Dr. Bayon so ably 
proved tonight, that there is only a minimum 
amount of danger in using quinidin. 


Dr. J. H. Musser; Two features of quinidin 
therapy that Dr. Bayon did not bring out in his 
paper — perhaps did not intend to bring out — 
might be explained. One is that quinidin has prac- 
tically no value in long continued cases of fibril- 
lation; if fibrillation has been of short duration 
quinidin may have a very excellent effect. An- 
other thing that should be mentioned, and that is, 
that a good deal depends on the eitology of the 
particular cardiac disturbance that is responsible 
for the auricular fibrillation. I do not wish to 
imply that we never get good results with quini- 
din; on the contrary, in a number of cases of 
rheumatic heart disease that have come under my 
observation, the effect of quinidin is sometimes 
brilliant. I must confess, with such a drug as 
digitalis on hand, which we use so frequently, and 
which has proved its value, it seems to me that 
quinidin should be reserved for a few selected 
cases only. Incidentally, there is another use to 
quinidin which was not mentioned (of course Dr. 
Bayon was discussing auricular fibrillation), the 
benefit you get with nervous individuals having 
frequent ectopics; if you put them on quinidin 
they will be very materially benefitted by having 
the frequency diminished, or the ectopics actu- 
ally stopped. Mentally at least this seems to 
help them quite considerably. 

Dr. Randolph Lyons: Dr. Bayon is to be com- 

plimented on his interesting paper. 

I would like to sound a warning about the 
use of quinidin in fibrillation. I have had a num- 
ber of cases of transient fibrillation where the 
fibrillation only persisted a few hours to a few 
days, in whom it was difficult to tell whether the 
cessation was due to the drug used. I give quinidin 
to patients that can not be controlled with digi- 
talis first, but when the fibrillation stops a few 
h.ours or days after administering it, I am not 
always certain that the change can be ascribed 
to the drug. 

I do not wish to imply that quinidin has not 
much value in the control of fibrillation, but that 
we have to be cautious in interpreting our re- 
sults; a good many of these cases of fibrillation 
would cease spontaneously without quinidin or 
any other drug. 

Dr. Geo. R. Herrmann: Dr. Bayon has indeed 

presented us with a complete resume of the liter- 
ature on quinidin. His unusually spectacular re- 
sults have, I fear, made him a bit partial to the 
drug. I cannot agree with his contention that 
the fibrillary auricle is just as likely to send forth 
broken off bits of thrombus which may act as 
emboli as is the auricle which has been changed 
from fibrillation to normal mechanism. As we 
all know in fibrillation there is no contraction of 
the auricle whatever. The fibrillary tremors ap- 
pear only in the dilated walls of an engorged, in- 


Sanders — Some Principles Underlying the Surgical Management 


31 


active auricle, and the effects of these fibrillary 
waves upon the content of the auricle is practi- 
cally nil, while when normal mechanism is re- 
sumed a coordinated pressure of the contents 
again comes into play. In cases in which the 
onset of auricular fibrillation is of recent date 
and in which there has been little oportunity for 
thrombi to form, conditions which are common to 
the auricular fibrillation of exophthalmic goiter, 
quinidin is, of course, the drug of choice since 
digitalis has very little effect on this type of 
auricular fibrillation. When other acute post- 
operative paroxysms or transient auricular fibril- 
lation or that that occurs in acute infectious dis- 
eases are encountered, quinidin is most certainly 
indicated, but for the disturbances that are pres- 
ent in chronic heart disease, it is, I feel certain, 
only the special case in w>hich the results are as 
brilliant as those that Dr. Bayon has experienced. 

It is, however, good to have clinicians who are 
brave enough to take the chance, for certainly 
the faint of heart and those who are gun-shy from 
accidents with the drug cannot hope to settle the 
matter, and probably frequently deny their pa- 
tients a drug which might be most useful. The 
contraindications, however, must be kept in mind. 
Idiosyncrasies to the drug must, of course, first 
be ruled out by minute test doses. It can do no 
harm to reiterate the fact that patients who have 
suffered embolism previously or who have vegeta- 
tive endocarditis or who have a high grade of 
heart failure or who have cardiac pain, that was 
relieved by the onset of fibrillation, should not be 
given quinidin. 


Late Results From TryparsamJde Therapy in Neuro- 
syphilis. — On the basis of his experience and a review of 
results after the lapse of from five to six years, W. F. 
Lorenz urges that every case of syphilis of the central 
nervous system be treated energetically. Tryparsamide and 
mercury offer a convenient and remarkably effective treat- 
ment. It is necessary to select cases in making a choice of 
tryparsamide, other arsenicals, malarial inoculation or other 
therapy of proved value. In the instance of tryparsanride, 
an extensive trial should be made before the drug is dis- 
carded. There are now many patients who have enjoyed 
health and efficiency for periods of from five to six years 
as the result of treatment with tryparsamide and mercury. 
These are largely cases that would have otherwise, without 
doubt, passed on to hopeless chronicity and death. As a 
result of this review, it is Lorenz’ conviction that absolute 
differentiatoin by either clinical or serologic evidence be- 
tween amenable and resistive cases cannot be made before 
a therapeutic trial. Early improvement is very encouraging 
and argues for a persistence of the effort instituted. Lastly, 
a point that cannot be too much emphasized is the practice 
of regarding every case as an individual problem in which 
all the evidence, clinical and serologic, must be weighed 
before planning the therapeutic attack. — J. A. M. A., April 
21 , 1928 . 


SOME PRINCIPLES UNDERLYING THE 
SURGICAL MANAGEMENT OF 
LESIONS OF THE STOMACH* 

R. L. SANDERS, M. D. 

Memphis, Tennessee. 

A discussion of duodenal ulcer is not 
within the scope of this paper. That is a 
subject of tremendous importance and 
should be the basis of a monograph. Chronic 
duodenal ulcer is probably the most com- 
mon surgical lesion of the upper intestinal 
tract, and yet it is fraught with the least 
of cancer potentialities. The duodenum 
possesses an extraordinary immunity 
against malignant disease and primary 
cancer is seldom found there. The pylo- 
rus is a sort of “dead line” across which 
cancer seldom passes. 

Ulcer of the stomach is a rare disease 
although early writers thought it to be of 
common occurrence. For all practical pur- 
poses, every gastric ulcer should be regard- 
ed as a potential cancer. Many gastric 
lesions which appear benign even after a 
careful roentgenologic study later prove to 
be malignant. Gastric ulcers undergoing 
carcinomatous transformation and early 
localized primary carcinomatous ulcers 
compose a group of most interesting and 
hopeful cases. One-third of all the can- 
cers in men and one-fifth of those in women 
occur in the stomach. No one can defi- 
nitely estimate the exact frequency with 
which benign gastric ulcer becomes malig- 
nant, Neither can it be determined how 
often cancer develops on pre-existing be- 
nign gastric lesions, Petterson places the 
percentage as low as 2 per cent while Mac- 
Carty once thought such a transformation 
occurred in 71 per cent of all cases. Some- 
where between these two extremes the ac- 
tual occurrence will be found. Although 
Eusterman has recently written more hope- 
fully regarding the prognostic value of 
gastric acidity in elderly people suffering 
from chronic gastric ulcer, yet the acid 


*Read before the North Mississippi Six County 
Medical Society at Water Valley, Miss. 


32 


Sanders — Some Principles Underlying the Surgical Management 


factor alone should not afford a sense of 
false security to such patients and keep 
them from obtaining the benefits of surgi- 
cal removal of the ulcer while it is in a 
curable state. The chief complaint in 
chronic ulcer is pain, usually regular. Thfi 
pain up to a certain period is relieved by 
food. The time of occurrence of the pain 
with reference to food intake will vary ac- 
cording to the location of the lesion. 

In our clinic about 25 per cent of the 
duodenal ulcers are treated surgically. 
When the patients are not sufficiently re- 
lieved by medical management, when bleed- 
ing occurs repeatedly, when obstruction in- 
terferes with adequate nutrition or when 
perforation occurs, the surgical indication 
is definite. When a demonstrable gastric 
ulcer is found and no contraindication 
exists, immediate surgical treatment is ad- 
vised. The results have justified this pro- 
cedure when the ulcer is accessible and 
amenable to surgery. The ulcer may be ex- 
cised with the knife or cautery and the ex- 
cision supplemented by a gastro-enter- 
ostomy. This operation has given most 
satisfactory results. If the ulcer is large 
and so located that a partial gastrectomy 
offers the patient a better chance for cure, 
a resection is done and, if possible, the con- 
tinuity of the intestinal tract restored by 
the Polya technic. In some instances the 
Bilroth No. 1 or No. 2 type of operation 
may be selected to meet certain indications. 

Occasionally a very large ulcer will oc- 
cur high up on the lesser curvature or 
posterior wall and be so inaccessible . that 
excision or resection is not technically 
possible. Some years ago Moynihan sug- 
gested treating such ulcers by making a 
large gastro-enterostomy opposite the 
crater of the ulcer and supplementing this 
by inserting a jej unostomy tube a few 
inches lower down the jejunum. The pa- 
tient may be nourished through this tube 
a sufficient time to allow the ulcer to heal. 
This method was used in one of our cases 
some five years ago. The patient was a 
woman 56 years of age who had a huge 
ulcer on the lesser curvature near the car- 


dia, perforating into the under surface of 
the liver. A posterior gastro-enterostomy 
was done and a jej unostomy tube inserted 
eight inches below the anastomosis, 
through which tube the patient was fed for 
120 days. No food nor drink was allowed 
by mouth until after the tube was removed. 
The fistula closed spontaneously and the 
patient made an uneventful recovery. She 
is entirely well and a recent roentgen-ray 
examination showed the stomach had prac- 
tically returned to normal condition. 

GASTRO-E NTEROSTOM Y. 

Gastro-enterostomy has the widest range 
of usefulness of all operations for benign 
lesions of the stomach and duodenum. 
When the indications are adequate and the 
technic of performance proper, gastro-en- 
terostomy leaves but little to be desired 
and complications are rare. Its simplicity, 
safety and efficiency make it the most 
firmly established of all operations on the 
stomach. It is true that the results are 
not always perfect but they probably reach 
a higher percentage of satisfaction than 
any other operation so far used. Gastro- 
enterostomy is unsurgical in principle but 
the most efficient makeshift so far devel- 
oped. It is occasionally necessary to dis- 
connect the anastomosis. Gastro-enter- 
ostomy has been done in two groups of 
cases: 1. The necessary; 2. The unnec- 

essary. According to Balfour the unneces- 
sary gastro-enterostomy discredits the 
surgeon but not surgery. Gastro-enter- 
ostomy done on account of conditions simu- 
lating ulcer, atony of the stomach, hemorr- 
hage not due to ulcer, etc., has brought the 
operation into more or less disrepute in the 
minds of many medical men and some sur- 
geons. The only necessary condition de- 
manding gastro-enterostomy is a demon- 
strable lesion of the stomach or duodenum. 
A necessary gastro-enterostomy may be 
followed by poor results. Occasionally 
the anastomosis may be poorly made, the 
location of the stoma improper or some 
intra-abdominal pathology overlooked or 
not removed at the time of the operation. 
These may be some of the reasons for such 
apparent failures. 


Sanders — Some Principles Underlying the Surgical Management 


33 


Recurrent or marginal ulcers occur in a 
small per cent of cases and usually demand 
another operation to disconnect the anas- 
tomosis. Gastro-jejunal ulcers may be 
caused by the same agent that produced 
the original ulcer if the cause has not been 
removed. It is probable that some patients 
are unusually susceptible to ulcer forma- 
tion. All foci of infection should be re- 
moved as early as possible when any ulcer, 
whether primary or secondary, is being 
treated. Marginal ulcers do not respond 
well to medical treatment. As soon as a 
definite diagnosis is made, the ulcer should 
be treated surgically by one of the following 
methods according to the indications: 1. 

If the original ulcer is healed and the pylo- 
rus not obstructed, a simple disconnection 
of the anastomosis will suffice. 2. Dis- 
connection and some type of pyloroplasty. 
3. Disconnection supplemented by a new 
gastro-enterostomy or a plastic operation 
on the old anastomosis after excising the 
ulcer. 4. Disconnection and partial gas- 
trectomy, preferably by the Polya technic. 

Gastro-jejunal ulcers occasionally per- 
forate into the colon. This complication 
has occurred in two of our cases. It is a 
formidable sequela and one that demands 
immediate separation of the colon, the 
stomach and the jejunum. Fortunately, 
simple separation was all that was neces- 
sary and resection was not done. Both 
patients have entirely recovered and are 
apparently in good condition. There has 
been no reactivation of the primary ulcer. 

Multiple ulcers are found far more often 
than they were formerly thought to occur 
and for this reason radical resection is 
gaining ground. In order that the ulcers 
may be removed at the time of the primary 
operation, partial gastrectomy is becoming 
more and more the operation of choice for 
many benign lesions of the stomach. It is 
safe and complete and removes the lesion 
whether single or multiple. In the hands 
of experienced surgeons the mortality from 
partial gastrectomy appears very little 
higher than from excision of the ulcer and 


gastro-enterostomy or gastro-enterostomy 
alone. 

CANCER. 

Some one has said that the body lines of 
cancer cross in the stomach. In the United 
States 100,000 people annually die of can- 
cer. Approximately 37,000 of these deaths 
are due to carcinoma of the stomach and 
liver. We know that primary cancer of 
the liver is rare and, eliminating this group, 
it is certain that well over one-third of 
cancer deaths are due to carcinoma of the 
stomach alone. 

In the sixteenth century the average 
length of life was about 22 years. Today 
the span is well beyond 56 years. Much 
progress has been made in salvaging the 
lives of infants and children, thus permit- 
ting a larger number of people to reach 
middle life. Cancer begins to take its 
toll, as a rule, at or beyond middle life, and 
on this account the relative proportion of 
cancer deaths is more apparent. Unfortu- 
nately, we are not yet able to salvage the 
same proportion of adult life as we have 
in infants and children. This is a problem 
that our present generation should endeav- 
or to solve. 

What can we do about it? There can be 
but one answer. Make early diagnoses. 
The treatment is perfectly plain. No can- 
cer of the stomach has ever been cured 
spontaneously or by medical means. The 
surgical removal of the malignant lesion 
while it is confined to a local area is the 
only hope for a permanent cure. 

The pessimistic attitude of the laity, as 
well as the profession, seems justified in 
the light of present conditions. We are 
creatures of tradition. This tradition is 
common to medical men and surgeons 
equally as well as to people in other walks 
of life. Our conception of cancer of the 
Stomach must be revised. All medical 
men are familiar with the text book picture 
of gastric carcinoma. The picture is one 
of the last stage symptoms depicting a pa- 
tient well beyond the bounds of curability. 
Just so long as text books and instructors 


34 


Sanders — Some Prmciples Underlying the Surgical Management 


continue to teach late stage symptoms of 
the disease, progress will be retarded in 
salvaging the lives of people suffering from 
lesions of the stomach. People must ap- 
preciate the fact that gastric carcinoma 
may exist with little or no loss of weight, 
no alteration of appetite, no anemia, with 
normal gastric acidity and without a palp- 
able epigastric mass. Laymen procrasti- 
nate in the fallacious notion that people 
past middle life all suffer more or less from 
dyspepsia. The majority of patients apply 
for examination late or long after the dys- 
peptic symptoms first manifest themselves. 
Lack of time or incomplete examination 
often fails to' reveal the potential or real 
condition in the stomach until after the 
period has passed when a cure might be 
affected. 

Since the advent of the roentgen-ray as 
an adjunct in diagnosis, competent roent- 
genologists have developed all over the 
country. Co-ordinate team work between 
the roentgenologist, the internist and the 
surgeon is making for progress. Thirteen 
years ago Friedenwald studied 1,000 cases 
of cancer of the stomach and found only 
28 per cent of them operable at the time 
they were examined. Three and threcr 
tenths per cent of that series were treated 
by radical resection. Eusterman has re- 
cently reported a large series of cases in 
which he found more than fifty per cent 
were operable, and forty-six per cent of 
that group were subjected to radical resec- 
tion. Thus we see that such team work 
and some education of the people along the 
lines of careful examination are accomplish- 
ing something toward the end of early 
diagnosis and extending the operability to 
a higher percentage of cases. Periodic 
health audit propaganda should be spread 
among the people generally, especially those 
beyond middle life. Any dyspeptic com- 
plaint should be warning sufficient to 
justify immediate examination in which 
are included the combined efforts of the 
internist, the radiologist and the laboratory 
man. If the history is suggestive and a 
deformity or filling defect is found, the 


surgeon should also become a member of 
the consulting group. 

Obstructive lesions at the pylorus pre- 
sent quite different symptoms to lesions at 
or near the cardia. Lesions in the pars 
media involving the lesser curvature, the 
anterior or the posterior wall, often remain 
quiescent until the disease is well advanced. 
A small circumscribed cancer near the pylo- 
hus may so nearly simulate a benign ulcer, 
even to the point of an intermittent course, 
as to deceive the most careful observer. 
Early surgical removal in such cases is a 
necessity. It is estimated that the primary 
location of cancer involves the cardia in 
less than one per cent. The lesser curva- 
ture is involved in about 25 per cent while 
the pyloric antrum is involved in 60 per 
cent. This fact alone places the surgical 
treatment well in the forefront of all reme- 
dies. If the reverse condition were true, 
and the cardia should be the common loca- 
tion, then surgery could be practically elim- 
inated in this process of salvaging cancer 
sufferers. The inaccessibility of the upper 
end of the stomach and the technical diffi- 
culties encountered in operating almost 
preclude surgical removal of lesions in that 
locality. 

There is a tendency on the part of the 
profession to try antiluetic therapy in many 
cases of gastric lesions. This procedure is 
probably not justifiable in the light of our 
present knowledge concerning the appalling 
number of deaths from cancer of the 
stomach, most of whom are victims of late 
diagnoses. Patients have improved under 
arsenical treatment but this is hard to ex- 
plain. Arsenic probably stimulates the 
blood centers, creates a better appetite and 
a sense of well-being, thereby building up a 
false security. Syphilis of the stomach is 
a rare disease while cancer is far too com- 
mon. If antiluetic remedies are used, their 
use should not extend over a long period of 
time and a careful roentgenologic check 
should frequently be made. 

PRE-OPERATIVE PREPARATION. 

Moynihan once said, “Surgery has been 
made safe for the patient; we must now 


Sanders — Some Principles Underlying the Surgical Management 


35 


make the patient safe for surgery.” Much 
can be done in the way of preparation to 
minimize the risk of operation for cancer 
of the stomach. iPatients who have been 
on a starvation diet, even though no ob- 
struction exists, can be benefited by a few 
days of rest in bed with a liberal diet and 
abundant fluids. In those cases with 
marked obstruction at the pylorus, the de- 
hydration and starvation are often pro- 
nounced and preliminary preparation is 
imperative. In the latter group of cases, 
blood chemistry studies are valuable in de- 
termining the amount of toxemia present. 
The chlorides will often be low. Much 
benefit may be derived by the intravenous 
administration of sodium chloride and glu- 
cose solution given once or twice a day for 
a short time prior to operation. The mar- 
gin of safety can be greatly extended by 
such preliminary treatment. 

Gastric lavage repeated every twelve 
hours should be done for a sufficient length 
of time to cleanse the stomach entirely. The 
stomach tube seldom does harm even in the 
most extensive gastric lesions. Washing 
out the debris and infected material will 
render the edematous stomach walls more 
healthy and permit better approximation 
and suture during the operation. Pyloric 
obstruction should not be considered an 
emergency condition comparable to ob- 
struction farther down the intestinal tract. 
Time spent in the preliminary preparation 
is valuable and avails much in the final 
outcome of many such cases. 

Cancer patients are often quite anemic 
when first examined. The anemia may be 
due to an actual loss of blood, to hemolysis 
from disease toxemia, or to both. Treat- 
ment of such secondary anemias is not al- 
ways satisfactory. It has been our custom 
to use blood transfusions preliminary to 
operation when the hemoglobin is below 50 
per cent. We rarely find an actual in- 
crease in the hemoglobin percentage after 
transfusion but the red blood cell count is 
often appreciably elevated. A general im- 
provement is noted and the patients ex- 
perience a sense of well-being, making 


transfusion valuable. A case in point 
will illustrate this beneficial effect. A 
man, 65 years of age, came to the clinic last 
fall on account of a large obstructing car- 
cinoma involving the pars media and py- 
loric antrum. He was a poor surgical risk. 
Blood examination showed the hemoglobin 
40 per cent and erythrocytes 2,500,000. 
Two blood transfusions of 600 cc. each 
were given by the direct method without 
reaction. Very little change was noted in 
the blood picture but the patient experi- 
enced a feeling of improvement, was able 
to go through the operation satisfactorily 
and made an uneventful recovery. A palli- 
ative gastro-enterostomy was done and he 
has been reasonably comfortable up to now, 
which is well more than six months post- 
operative. This case serves also to empha- 
size the fact that the mortality as well as 
the technical difficulties of the operation 
can be materially influenced by timely at- 
tention to proper preliminary preparation. 

ANAESTHESIA. 

The choice of an anaesthetic should be 
considered along with the other major fac- 
tors influencing the treatment of this 
group of cancer cases. It is well known 
that pulmonary complications more fre- 
quently follow operations in the upper ab- 
domen than elsewhere in the body. This 
is especially true in cases of stomach re- 
sections where extensive operations tend 
to fix the diaphragm and limit the res- 
piratory movements. Postoperative pneu- 
monias often are fatal in old, dehydrated 
and debilitated patients. The anaesthetic 
used, therefore, should be one that least 
disturbs the pulmonary tissues. It has 
been frequently noted that operations done 
under local anaesthesia do not eliminate 
pulmonary complications. Apprehensive 
patients may be injured more by using only 
local than by a properly selected general 
anaesthetic. The combined use of local 
anaesthesia and ethylene gas has been very 
satisfactory in our work, and the pulmonary 
complications have been reduced to a mini- 
mum. 


36 


Sanders — Some Principles Underlying the Surgical Management 


OPERATION. 

The golden rule should always be applied 
in determining the type of operation to be 
done in such grave diseases as cancer of the 
stomach. The first aim should be to cure 
the patient. Finding cure humanly impos- 
sible, the next step should be to prolong 
life, minimize suffering and add to the com- 
fort of the patient during his remaining 
days. Often this can be done by the use of 
some palliative type of operation. In a 
large number of cases the average length 
of life, following palliative gastro-enteros- 
tomy, has been seven months. Where no 
operation was done, a similar group of 
patients lived six months after the exam- 
ination. An average gain of one month in 
the span of life and added comfort during 
the declining days may justify an opera- 
tion. Occasionally, however, one is re- 
warded by an unexpected cure following a 
resection of the stomach when the case at 
the time of exploration was apparently well 
advanced beyond hope. With the excep- 
tion of those considered by a competent 
roentgenologist to be inoperable, all cases 
not showing definite evidence of metastases 
should be offered the benefits of an explora- 
tion. When the disease is limited to the 
stomach and adjacent lymph-nodes and 
does not extend too high to permit a safe 
anastomosis, the surgeon is usually war- 
ranted in doing radical resection. The size 
of the tumor does not always determine its 
resectability. Often a large movable can- 
cer can be removed with greater ease than 
a smaller one that has become fixed to the 
adjacent structures. The size of the lym- 
phatic glands is not a safe criterion in de- 
termining the extent of metastases. If the 
surgeon has the benefit of a pathologist 
near at hand, a gland can be removed and 
a section quickly made. One will often find 
such lymph-nodes, even though large, en- 
tirely inflammatory. Ordinarily a resec- 
tion should not be done when metastases 
exist in other organs, but occasionally re- 
moval of the growth is justified even though 
small nodules are found in the liver. Such 
secondary invasions may grow slowly and 


the patient’s life be prolonged with lasting 
good results. In cases of frankly nonresec- 
table cancers of the stomach, there has been 
a higher operative mortality following sim- 
ple palliative gastro-enterostomy than has 
been recorded in the less advanced cases 
where a radical resection has been done. It 
is to be noted in the former group of cases, 
that the patients are very sick and are, 
therefore, poor surgical risks. Surgeons 
should, therefore, be very careful in the ex- 
ploration and decision for or against radi- 
cal resection. 

Crile has emphasized the importance of 
a two-stage operation. The gastro-enter- 
ostomy is to be done first, followed two 
weeks later by the resection. Attention to 
preoperative preparation, however, will 
lessen the need for such a procedure. In 
cases of marked obstruction where a resec- 
tion is not advisable, a palliative gastro- 
enterostomy should be done. The posterior 
operation is more satisfactory, but on ac- 
count of fixation the stomach cannot always 
be drawn through the transverse mesocolon 
and, therefore, an anterior anastomosis is 
the only choice. It is surprising how com- 
fortable many patients are made following 
such palliative short-circuiting operations. 
They often gain weight and color and the 
appetite becomes much improved. The de- 
clining days are much more endurable after 
the obstruction has been overcome. 

In the event resection has been done, 
there are several ways the continuity of the 
intestinal tract may be restored. The Bil- 
roth I is carried out by direct union of the 
duodenum to the stomach. This is not 
always satisfactory in cancer cases on ac- 
count of the tendency of the disease to recur 
at that point, making obstruction possible 
later on. The end of the duodenum and 
that of the stomach may be closed and an 
independent gastro-enterostomy done, 
which is Bilroth’s second type of operation. 
This procedure has its advocates and is a 
very satisfactory operation. The Polya 
type of anastomosis is probably the most 
popular and deservedly so. It is made by 


Sanders — Some Principles Underlying the Surgical Management 


37 


uniting the proximal end of the stomach to 
the side of the jejunum through the trans- 
verse mesocolon as a posterior operation. 
When the stomach is too short to be drawn 
down through the transverse mesocolon, 
the ante-colic anastomosis of Balfour can 
be satisfactorily done. To avoid obstruc- 
tion and retrograde distension of the duo- 
denum, this operation should be supple- 
mented by an entero-anastomosis uniting 
the proximal and distal loops of the 
jejunum. 

POSTOPERATIVE TREATMENT. 

Gastric lavage should be used frequently 
in case the stomach does not drain well. It 
can do no harm and by washing out old 
clots and offensive accumulated fluids often 
adds much to the comfort of the patient. 
Healing is promoted and by securing ade- 
quate drainage, the stomach resumes its 
function more rapidly and the convalesc- 
ence period is shorter. Fluids should be 
given frequently and in large quantities. 
We are using 1000 cc. of 2 per cent glucose, 
alternating with salt solution every eight 
to twelve hours during the first three days 
postoperative. A 5 per cent glucose con- 
tinuous proctoclysis is used to supplement 
the fluid intake. All fluids and food by 
mouth should be withheld for a period of 
two or three days. Sips of hot water are 
tolerated better than cold. Liquid diet 
should be started on the fourth day and 
gradually increased until at the end of a 
week the patient is taking a fairly liberal 
diet. It is surprising how little shock is 
experienced by such extensive resections. 
Stimulants are rarely necessary. Wound 
infection seldom occurs and the patients 
are usually up on the twelfth day and ready 
to leave the hospital as early as the average 
gall-bladder or other abdominal operative 
patients. 

Fifty per cent of the patients live three 
years or m|ore if the operation is done 
before the regional lymph-nodes are in- 
volved. A few permanent cures will be 
effected. When the adjacent lymph glands 
are involved with the malignant process at 
the time of the resection, the three year 


cures drop to 20 per cent or less. In the 
future, early diagnosis is our only hope for 
a satisfactory treatment of this desperate 
group of cases. Very little progress has 
been made in the clinical interpretation of 
cancers of the stomach, probably on account 
of the lack of symptoms present in many 
cases. As mentioned before, the roentgen- 
ray as an aid has been the outstanding 
agent in promoting early diagnosis. A 
competent roentgenologist will make the 
correct diagnosis in 95 per cent of all gas- 
tric lesions, three out of four of which are 
malignant. 

The appalling number of cancer sufferers 
should be sufficient to justify every one in 
having a periodic health examination. This 
examination should be repeated from time 
to time, and in case dyspeptic symptoms of 
any nature should arise, a competent in- 
ternist and a roentgenologist should be con- 
sulted. If the individual is beyond middle 
life, the examination should always include 
a roentgen-ray study of the stomach and in- 
testinal tract. Not until our people are 
educated to ai realization of the prevalence 
of this terrible malady will we begin the 
real business of salvaging our middle aged 
and elderly people. A decade or two of in- 
tensive education, periodic health audits 
and properly applied early surgical treat- 
ment will enable us to reduce the annual 
100,000 death rate to a much smaller num- 
ber. 


Martyrs of Medicine. — The prizes that the world awards 
for such self-sacrifice and martyrdom are not great. The 
public has not yet learned to appreciate the type of cour- 
age that such men display. The investigative spirit that 
drives them is little understood by the average man. In- 
deed, few appreciate the type of mind that caused physi- 
cians in the past to suck the infectious membrane from 
the throats of children strangling with diphtheria, that 
caused hundreds of T)hysicians to expose themselves to 
smallpox, to plague and to influenza in their devotion to 
duty. Such martyrs are merely living up to the traditions 
of their calling estabilshed thousadns of years ago. The 
death of an investigator like Noguchi, whose value to 
humanity is incalculable, serves but as an opportunity 
again to remind the public of the trials that medical men 
undergo and of the service that they render. — J. A. M. A., 
May 26, 1928. 


38 


Donald — The Gall Bladder 


THE GALL BLADDER. 

ITS PATHOLOGICAL CHANGES AND 
SURGICAL TREATMENT, 

D. C. DONALD, M. D., 
Birmingham, Alabama 

The gall bladder and its bile ducts are 
developed from the same mass of cells as 
the stomach, duodenum, and pancreas ; 
made up of four coats, the mucous, the 
muscular, the elastic, and the serous. The 
nerve supply arises by a filament from the 
vagus, furnishing the motor and secretory 
impulse to the gall bladder and its bile 
ducts, and inhibitory fibers to the sphincter 
of the ampulla of Vater; sensory filaments 
from the right ninth intercostal segment 
joined with the sympathetic is known as 
the inhibitory nerve for muscular structure 
of the gall bladder. 

The gall bladder is a sac with a capacity 
of 0.75 to 1.5 ounces. The older physiol- 
ogists maintained its chief function was to 
serve as a reservoir for the bile during 
the interval of digestion. The spiral valve 
found in the common duct at the junction 
of the hepatic and cystic duct aids the fill- 
ing of the gall bladder during the inter- 
val of digestion. The gall bladder is richly 
supplied in lymphatic tissue, has great 
power of absorption and its mucous mem- 
brane is arranged to bring the contents in 
contact with as much surface as possible. 
The muscular walls are diffuse and weak. 

Anatomically the gall bladder is best 
fitted for absorption, the muscular coat aids 
in mixing and bringing its contents in con- 
tact with the mucosa. Many years elapsed 
before the old idea of the gall bladder per- 
forming any function other than the power 
of holding and discharging the same 
amount and quality of bile as discharged 
by the liver. The gall bladder of today is 
known to have a great function in health, 
largely conermed by the laboratory work- 
ers, MannG), Graham and Cole*^), and 
many others. 


Invasion of the pathogenic organisms at- 
tacking its mucous membrane and deposit- 
ing connective tissue, blocking the lympha- 
tics, changes this organ, which plays such 
an important part in health, to one that acts 
as a focus of infection and if not recognized 
and removed will be the underground soil 
for invalidism. Today many cases of dia- 
betes mellitus, chronic cardio-vascular dis- 
ease, and arthritides would be in the class 
of health were it not for the undiscovered 
primary focus in the gall bladder and bile 
ducts. 

It is agreed by physiologists who have 
collected data from laboratory experiments 
on the lower animals that the gall bladder 
has the power of : 

(1) Regulating pressure within the bil- 
iary tract, 

(2) Concentration of bile by absorption 
of its water or fluids, 

(3) It has been suggested but not con- 
firmed that blood from the gall bladder 
empties into the portal vein. It is possible 
that something is formed in the gall blad- 
der necessary for the liver. Cited by Gra- 
ham and Cole.<2) J, E. Sweet<®> has brought 
evidence suggesting the gall bladder forms 
something which acts to de-esterize choles- 
terol esters. It has been shown that bile 
in the gall bladder is eight to ten times as 
concentrated as it is possible for the liver 
to make it, or found in the hepatic duct. 
During the period the bile is in the gall 
bladder active absorption of its fluid occurs, 
passing to the blood stream by lymphatics. 

The idea has been advanced that the gall 
bladder haS control of its own cystic duct 
in order to cause pressure filtration of the 
fluids of the bile. Sweet, with many other 
physiologists, thinks under normal condi- 
tions only a small amount of bile which en- 
ters the gall bladder leaves it by way of the 
duct; the parietal pockets along the intrin- 
sic and extrinsic hepatic ducts and so-called 
glands of Luscha which in realty are small 
pouches in the mucous membrane of the 


Donald — The Gall Bladder 


39 


gall bladder are points in which active ab- 
sorption occurs. 

Early morning operation usually finds 
the gall bladder well filled (fasting time). 
The liver manufactures bile at varying 
speeds but constantly, the digestive activ- 
ity requiring relaxation of Oddi’s muscle 
to care for the extra amount and variety 
of food. As soon as the ingested food passes 
the pylorus the acid chyme causes relaxa- 
tion of the sphincter at the end of the 
chole-duct and co-ordinately with this the 
gall bladder expels a portion of its contents. 
The bile salts are quickly absorbed from the 
intestine with an increased liver activity 
to secrete more bile. During this time more 
bile passes into and from the gall bladder. 
Later the stomach becomes quiet and chyme 
not passing over the papilla, the sphincter 
opens less frequently, and gradually the 
secretory action of the liver is reduced to 
fasting time. 

Gall bladder infections are most fre- 
quently seen from forty to fifty years of 
age. However, neither young or old are 
barred from the disease. Records show 
that stones have been found in a child of 
ten, and not infrequently today we find 
patients with gall bladder disease in pri- 
vate practice or clinics, occurring at sev- 
enty years and over, associated often in 
advanced life with extreme maladies, such 
as carcinoma of the gall bladder, carcinoma 
of the stomach, or carcinoma of the pan- 
creas. 

The lymph stream is the chief route for 
gall bladder infection to occur; ascending 
infection from the intestinal flora is less 
frequent. Typhoid bacilli, streptococci, 
pneumococci, and the colon bacillus group 
are the bacteria most commonly found in 
infections of the biliary system. The ty- 
phoid bacillus inhabits the mucosa and 
muscular wall of the gall bladder in the 
early teens, patient remaining free of di- 
gestive complaints until middle life when 
the following complaints are oifered. Flat- 
ulence, coming on several hours after eat- 
ing ; upper abdominal distress or pain, most 


frequently about one or three o’clock at 
night, located in the upper right quadrant 
and running into back and shoulder re^ 
gion. 

Pathologically the picture is one in which 
there are areas of connective tissue de- 
posits in the walls of the gall bladder. Mu- 
cus and dead bacteria often form the nu- 
cleus for the bile salts to be deposited for 
future stones ; tonsils, diseased gums, and 
abscessed teeth act as frequent foci for 
gall bladder infection. Pyorrhea alveo- 
laris is responsible for a large percentage 
of gastro-intestinal infection, such as gas- 
tric or duodenal ulcer, appendix or colon 
disease. Bile obtained from gall bladder 
specimens will be eighty to eighty-five per 
cent sterile, whereas microscopical section 
from the gall bladder will give a high per- 
centage of positives for increased deposit 
of connective tissue. The gall bladder has 
been cited above as an organ for filtration 
of bile. After the bacterial invasion this 
function is decreased or destroyed, accord- 
ing to the pathology that has occurred in 
its walls. 

Mann > produced chemical cholecystitis 
by injecting into the blood stream 10 c.c. 
of chlorinated soda (Dakin’s solution) to 
each kilogram of body weight. A, section 
of the gall bladder as early as six to twenty- 
four hours revealed definite pathological 
changes, as infiltration leukocytes and dila- 
tation of the blood vessels extending into 
the muscularis. Through other experi- 
mental investigation for gall bladder filtra- 
tion the animals were anesthetized and un- 
der surgical technique the common duct 
was doubly ligated and excised between the 
ligatures ; bilirubin did not appear in the 
blood or urine in any appreciable amount 
for twenty-four hours following, jaundice 
not earlier than four days. If the gall blad- 
der was removed or the cystic duct ligated, 
bilirubin would appear in urine and blood 
in three hours, jaundice in twenty-four. 

Nature has placed on each common, he- 
patic, and cystic duct at least one lymph 
node, occasionally two . They have a defi- 


40 


Donald — The Gall Bladder 


nite size in health. If found enlarged at 
operation it is an indication of excess fil- 
tration of the gall bladder, size of the gland 
depending on the filtration or amount of 
infection present. 

Vincent Lyon<®> of Philadelphia, was 
first to push forward in current literature 
the aifect of medical duodenal drainage for 
gall bladder disease with a twenty per cent 
solution of magnesium sulphate introduced 
into the duodenum through the Reyfus 
tube. This relaxes the sphincter and stim- 
ulates the flow of bile. Bile from the gall 
bladder evidently constitutes part of the 
bile. Stimulating agents such as three to 
five per cent hydrochloric acid applied to 
the ampulla raises the pressure in the com- 
mon duct to 600 to 800 m.m. through the 
spasm of the sphincter muscle. Fifteen to 
thirty m.m. is back pressure found in com- 
mon and hepatic ducts of animals without 
normal gall bladder (Mayo) In man the 
removal of gall bladder does not produce 
any appreciable change in the common duct 
pressure in normal life. Common duct ten- 
sion, taken under anesthesia, is 75 to 100 
m.m, of bile; in the gall bladder it varies 
from 100 to 200 m.m. of bile. Such pres- 
sure within the gall bladder, versus that in 
the common duct, is capable of filtering the 
fluids from the bile and increasing the con- 
centration eight to ten times over that of 
the common and hepatic ducts. 

QuainC^> has found that the common duct 
traverses the duodenal wall in an oblique 
way for a distance of 2 to 3 c.m. Copier 
and Kodoma<®> (cited by Graham and Cole) 
say that this angulation of the duct to the 
bowel and the distance the bowel wall is 
traversed by the duct constitutes a sphinc- 
ter-like mechanism dependant on tonicity 
of the intestine and makes it possible for 
the intestinal peristalsis to be a factor in 
regulating the flow of bile from the com- 
mon duct. Concentration and relaxation 
of the duodenum govern the duct drain- 
age. Intervals between the peristalfic waves 
of the duodenum encourage the emptying 
of the common duct. 


Boy den Sosman<“h and others have 
shown that a meal rich in fat, such as egg 
yolk and cream, has more relaxing effect on 
the bile duct and gall bladder, reducing the 
cholecystographic shadows IV 2 to 2 hours 
quicker than magnesium sulphate. Roun- 
tree<^2) and Geraghty*^^) after demonstrat- 
ing with the different anilin dyes found 
phenol-sulpho-phthalein to leave the blood 
by the kidney route and has proven an in- 
valuable aid in determining the secretory 
power of the kidneys. 

Cholecystography, by Graham and 
Cole<^®>, by the administration of tetra 
sodoiodide-phenol-sulpho-phthalein either 
orally or by the intravenous route has in- 
creased the positive diagnosis of gall blad- 
der disease 85 to 90 per cent. Former 
roentgen-ray study of the gall bladder and 
gastro-intestinal tract gave positive diag- 
nosis of gall bladder disease in 8 to 10 per 
cent. The salt is secreted by the liver; 
when the impregnated bile leaves the liver 
and passes into gall bladder it becomes con- 
centrated. Its shadow reveals the approx- 
imate size, coats, non-visualized cholesterin 
stones, time of filling and emptying. 

The cases in which we fail to obtain any 
information from the test are as follows: 

1. Those in which insufficient amount 
of the substance reaches the liver. 

2. Inability of the liver to secrete a suf- 
ficient amount. 

3. Blocking of the cystic duct. 

4. Failure of the gall bladder to con- 
centrate the material sufficiently, due to 
diseased gall bladder wall or too rapid emp- 
tying of gall bladder from the duodenal 
peristalsis. 

When the yellow flag of jaundice is raised 
in disease of the biliary system and its ac- 
cessory organs the surgical prognosis is 
usually bad. Jaundice is either hemolytic 
or obstructive in type. Stones lodged in 
the common duct are the usual or most fre- 
quent cause. The ampulla and middle third 
of duct are the points where stones are 


Donald — The Gall Bladder 


41 


most frequently placed and are usually 
milked from the gall bladder. 

Operation may show chronic gall bladder 
with or without stones. Stones can pass 
from the gall bladder and remain in the 
common duct without producing symptoms. 
At operation the gall bladder may not show 
any gross pathology, microscopical section 
may be the only mode of estimating the 
diseased tissue. 

Symptoms of Charcots disease appear 
when the stone completely blocks or trau- 
matizes the mucosa and invites mixed in- 
fection. Often a diagnosis of chronic ma- 
laria is advanced but not confirmed by 
blood smear. The chills and fever have no 
regularity. Heavy sweats and extreme 
prostration follow the fixation of the stone. 
Calcium salts, 10 to 15 grains three times a 
day for ten to fourteen days, forced fluids, 
rest in bed and attention to elimination, 
puts this type case in best condition for 
surgery, but no definite improvement comes 
until the stone is removed and the duct 
drained. The gall bladder should be re- 
moved at the same time if there is no malig- 
nancy of pancreas or ampulla. 

Strictures of the common duct are best 
treated if resulting from stone irritation, 
and if the stricture is not too dense, by re- 
moving the stone; draining the duct three 
to four weeks with rubber tubing, and cho- 
lescystectomy. If the gall bladder is not 
removed the stricture is reinfected by the 
diseased gall bladder. 

Cholescysto-duodenostomy or cholecysto- 
gastrostomy is indicated after removal of 
the stone if its bed shows massive scar tis- 
sue. Internal drainage into the stomach or 
intestines solves the problem. 

Malignancy of the ampulla or pancreas, 
or growth of head of pancreas requires 
drainage. Cholecysto-gastrostomy or cho- 
lecysto-enterostomy will give better results 
than placing the tube in the gall bladder 
for external drainage. 

Cholecystectomy is the choice operation 
for acute or chronic cholecystitis. Chole- 


cystostomy is indicated where the infection 
has extended into the bile ducts, with in- 
flammation of the pancreas. Secondary 
cholecystectomy may be necessary to restore 
the patient to health, but should not be done 
at primary operation in the presence of 
general infection of bile ducts and pan- 
creas. 

Gangrenous gall bladder should be re- 
moved, with drainage by means of a small 
rubber catheter in the common duct at the 
cystic duct junction. The catheter should 
be directed to the hepatic surface rather 
than toward the bowel. Often the end of 
the catheter passes into the bowel lumen 
and invites infection. Allow the catheter 
to remain three weeks or longer. 

Abscess, or suppurative cholecystitis 
should be drained by cholecystostomy. In- 
fections extend, by lymphatics, to the liver, 
portal vein, post-peritoneal space, omen- 
tum, etc. 

The surgeon should exercise great care 
and judgment in pathology of the gall blad- 
der and ducts. He should note the thick- 
ness of gall bladder wall, relationship and 
pathology of neighboring structures, such 
as adhesions of omentum to gall bladder. 
A gentle milking of the gall bladder ■will 
note the ease of draining its contents. The 
much spoken of strawberry type of gall 
bladder will have a delayed emptying time 
for cholecystography. The mucous mem- 
brane of the cystic duct often becomes thick- 
ened by extension from the gall bladder. 
Examine carefully for stones in the cystic 
duct. Careful probing of the common duct 
has discovered small imbedded stones in the 
duct or ampulla, whereas, palpation of the 
duct failed to reveal stone. 

An upper right rectus incision from the 
rib border downward, to enable good ex- 
posure of gall bladder and bile ducts, is 
the most useful incision. Do not cut the 
post-rectal fascia and peritoneum for the 
last two inches in the lower angle of inci- 
sion, this will not interfere "With retraction 
and will minimize the chances for postop- 
erative hernia. 


42 


Rives — Post-Operative Treatment 


Drain all cholecystectomy cases. Excise 
cystic duct close to the common duct, avoid 
any trauma to common duct, transfix drain, 
preferably a medium sized soft rubber tube, 
with No. 1 plain catgut to distal end of cys- 
tic duct, allow to remain until it loosens, 
eight to ten days following operation. 

CONCLUSIONS. 

(1) The gall bladder is peculiarly fitted 
for its power of absorption by wide distri- 
bution of its mucous membrane, thin mus- 
cular coat capable through the wide con- 
traction of its fibres of bringing the mu- 
cous membrane in contact with the bile, 
rich supply of lymphatics, and control of 
the cystic duct. In health this organ has 
great function : i. e., absorption of its fluids 
and regulating the pressure within the bil- 
iary tract. 

(2) Disease changes the gall bladder 
from an asset in health to a liability, and 
if not recognized and treated will act as a 
focus for infection. 

(3) Cholecystography in gall bladder 
disease gives information in 85 to 90 per 
cent of the cases, whereas former roentgen- 
ray of gall bladder and intestinal tract gave 
only 5 to 10 per cent positive findings. 

(4) Jaundice gives the surgical case 
poor prognosis, and should be given medical 
treatment in an institution for two weeks 
or longer before operation. 

(5 Pathology found at operation as to 
biliary tract, pancreas, bowel, and liver 
should be the guide to operative procedure. 

(6) Drain all cholecystectomy cases 
with a small soft rubber tube transfixed 
to the stump of the cystic duct. 

BIBLIOGRAPHY. 

1. Mann, Frank C. : Physiologic consideration of the 

gall bladder. J. A. M. A., 83:829-832, 1924. 

2. Graham, -E. A., & Cole. W. H. : Roentgenolic examin- 

ation of the gall bladder. J. A. M. A., 83 :613-614, 1924. 

3. Sweet, J. E. : Cited by Graham & Cole, above. 

4. Lyon, B. B. Vincent : The treatment of catarrhal 

jaundice by a rational, direct and effective method. Amer. 
Jour. Med. Sc., 160:503-512, 1920. 

5. Mayo, Chas. H. : The gall bladder of 1926. Annals 

of Surgery, 83:358-365, 1926. 


6. Quain: Cited by Piersol’s Anatomy. 

7 & 8. Copier, G. H., & Kodoma, Shuichi: The filling 

and emptying of the gall bladder. Jour, of Exp. Med., 
44:65-74, 1926. 

9 & 10. Boyden & Sosman: Cited by O’Brien, Fred W.; 

Cholecystography. Bos. Surg. & Med. Jour., 194:522-529, 
1926. 

11. Rowntree, L. G., & Geraghty, J. T. : The phenol- 

sulphonepthalein test for estimrating renal function. J. A. 
M. A., 57:56:811-816, 1911. 


POST-OPERATIVE TREATMENT: 
SOME PERSONAL IMPRESSIONS.* 

J. D. RIVES, M. D., 

New Orleans. 

We are frequently asked by students 
and internes to outline a routine of post- 
operative treatment. In answering this 
question we have so often found ourselves 
in conflict with widely accepted doctrines 
that it seems worth while to record our 
views. I say we because most of what I 
know of the subject has been learned from 
Dr. Urban Maes, and the conclusions given 
here have been derived from my ovm ex- 
perience obtained to a large extent from 
his service. I shall not try to cover the 
■whole field nor to give details of technique, 
but shall limit myself to the management 
ment of the usual uncomplicated abdominal 
case with brief comment on a few of the 
more common complications. 

Our principal article of faith is the belief 
that post-operative treatment is the most 
annoying, if not the most dangerous, com- 
plication to which patients are subjected. 
That being the case it should be reduced to 
a minimum, and no deviation made from 
the usual living habits of the patient, ex- 
cept for reasonable and demonstrable 
cause. Consideration of fundamental prin- 
ciple of physiology and pathology should 
determine every move. 

When the operation is completed and a 
light comfortable bandage applied, the sub- 
ject should be made dry and warm -without 


*Read before the Orleans Parish Medical So- 
ciety, December 12, 1927. 


Rives — Post-Operative Treatment 


43 


delay or unnecessary exposure. Properly 
clothed and wrapped in warm blankets he 
should be transferred to his bed which has 
been warmed to receive him. No oppor- 
tunity for loss of body heat is permissable. 
Chilling reduces resistance to infection, 
predisposes to pulmonary complications, 
and aggravates shock. 

If a general anesthetic has been used the 
anesthetist should be in constant attend- 
ance until a competent person can assume 
his responsibilities. Before the patient 
leaves his hands, the upper respiratory 
tract must be cleared of mucus and debris, 
preferably by suction. If for any reason 
we are in doubt as to the emptiness of the 
stomach, it should be washed before the 
throat reflexes are allowed to return. The 
lower jaw must be supported to prevent 
blockage of the pharynx by the base of the 
tongue until swallowing shows the return 
of reflexes. The head should be turned as 
far as possible to one side to prevent 
aspiration of vomited material, or if neces- 
sary the patient may be turned on his side 
when vomiting occurs. This care is ex- 
tremely important and should not be dele- 
gated to orderlies or untrained nurses. 
Deaths from aspiration of vomitus with 
asphyxia are not uncommon, and we have 
had the extremely disconcerting experi- 
ence of seeing our patient leave the operat- 
ing room with a single orderly in charge 
and arrive in his ward dead, with his at- 
tendant complaisantly unaware anything 
untoward had occurred. In addition to 
this immediate risk we have the more com- 
mon ones of aspiration pneumonia and 
pulmonary abscess. While I agree with 
Cutler, Holman and others that infarction 
accounts for a great many pulmonary com- 
plications, the evidence of David Smith has 
convinced me that aspiration of exudate 
from tonsil follicles and from infected 
gums, is also an important factor. 

The patient, after being safely returned 
to his bed, has three imperative needs; 
namely: rest, fluids and nourishment. Of 
these we consider rest the most essential 


one, the only immediate one in uncompli- 
cated cases, and subordinate all other post- 
operative care to its demands. 

Rest of course connotes relief of pain 
and the greatest possible bodily comfort. 
It is best obtained by administering mor- 
phin in adequate dosage and then permit- 
ting our victim to enjoy its effects. No 
other drug approaches morphin in its 
effectiveness and in those few cases of 
idiosyncrasy to it, I have uniformly failed 
to get satisfactory results from substitutes. 
I would emphasize two things in the use of 
morphin; first, that it be given in full 
dosage, not less than i/i grain for an adult 
weighing 125 pounds, or over; second, that 
it be given early. The first dose is best 
injected before recovery from anesthesia 
and succeeding doses before pain has bro- 
ken the patient’s morale. It should be given 
freely for the first 24 hours, being limited 
only by slowing of respiration below 16 per 
minute. For another 24 hours it may be 
given sparingly. After 48 hours it is of 
little or no value for the pain experienced 
is usually that of disordered peristalsis, 
widely and unfavorably known as “gas 
pains.” These pains are simply prolonged 
by narcotic drugs. Large hot stupes fre- 
quently or continuously applied, together 
with a rectal tube afford most relief. 
Enemas and flushes should be avoided at 
thisi stage. If pain is controlled and bodily 
comfort provided by careful attention to the 
details of good nursing rest is prevented 
only by anxious friends and relatives and 
undue zeal in post-operative treatment by 
his physician. A little tact on the part of 
the physician will avoid the former and a 
little common sense, the latter. 

Fluids are essential to the maintenance 
of circulation and elimination ; possibly 
they are of value in diluting toxins. At 
any rate, the need is real and demonstrable. 
However, due largely to the work of Crile, 
who has done more than any one man to 
improve post-operative care, the adminis- 
tration of fluids has become a fetish prac- 
ticed with more zeal than discrimination. 


44 


Rives — Post-Operative Treatment 


If a patient is dehydrated, the condition 
must of course be corrected either before 
or after operation, preferably before. But 
in the usual operation of election and in 
many emergencies, no such condition exists. 
The relative dehydration is not excessive, 
serious, nor urgent and will usually be cor- 
rected in ample time by oral administra- 
tion. The usual 1500 to 2000 c.c. is ample, 
and even that may be postponed safely 
until the initial nausea subsides. Of course 
if vomiting persists other avenues must be 
used, but this does not commonly occur. 
Proctoclysis is quite effective, if properly 
carried out and suffices for all ordinary 
needs. In the light of our experience with 
studied restraint, it is astonishing to see 
sane and conservative surgeons insist on a 
daily intake of 4000 to 5000 c.c. in uncom- 
plicated cases, while at the same time 
urging that rest is of first importance. I 
am quite unable to see how rest and 5000 
c.c. of fluid can be given in the same 24 
hours. It is stated that hypodermoclysis 
by the Bartlett method is painless and that 
is no doubt true, but no one can say that 
it is compatible with comfort. Our own 
experience has convinced us that given a 
case not dehydrated, not in shock, not 
severely toxic, and not unduly nauseated, 
the disturbance of rest attendant on the 
forcing of fluids by the various mechanical 
methods does more harm than the fluids do 
good. Our practice is to give cracked ice 
and ice water by mouth as soon as con- 
sciousness returns and continue with in- 
creasing quantities until a normal intake is 
achieved. No attempt is made to force 
fluids at any time, unless for special 
indications. 

Nourishment is handled in the same way. 
Liquids are given freely in small doses, as 
soon as nausea subsides. Hot drinlcs are 
tolerated better than cold in some in- 
stances, but no rule can be formulated. 
Hot tea and coffee, or broth, may be used. 
Fruit juices sweetened or not as desired 
are particularly satisfactory and the cold 
carbonated drinks, such as coca cola are 
frequently retained when nothing else is. 


Sugar is the most valuable food element at 
this stage, and the current superstition, 
that fruit juices and carbonated drinks 
cause gas pains, has no support in physi- 
ological, nor clinical evidence. Soft food, 
including toast, soft eggs, cereals, etc., may 
be started usually on the third or fourth 
day. It is probably best to be guided by 
the patient’s desire for food, rather than 
by the calendar. It is worthy of note, how- 
ever, that persistent nausea without or- 
ganic cause will sometimes respond 
promptly to a small dry meal. Milk must 
be considered as a solid, since it coagulates 
in the stomach, and its use postponed until 
solid food is given, usually about the fifth 
to the seventh day, depending on the 
patient’s expresse desire for it. We have 
followed this regime for nine years and 
note the result with great satisfaction. 
The only important modification commonly 
practiced is a rather rigid restriction of 
proteins and fats in liver and gallbladder 
cases during recent years, following the 
reports of Walters and his co-workers. It 
must be remarked here that Dr. Allen 
Eustis has insisted on this precaution for 
many years, with very little local encour- 
agement or support. Nourishment is not 
an immediate need in operations of elec- 
tion and in those emergencies where 
normal nutrition was kept up until just 
before operation. If patient’s are not 
starved pre-operatively, they will stand 24 
hours starvation without acidosis or other 
ill effects, so there is no real need for glu- 
cose by hypodermoclysis or infusion, unless 
complications arise. As for the use of solid 
food early, it is well to remember that if 
the stomach functions all food, except 
sugar which is absorbed high in the in- 
testines and wood fiber which is not 
absorbed at all, is very much the same sort 
of material when it reaches the ileum. 

In the care of the bowels we meet the 
powerful influence of ancient traditions. 
The pre-operative purge that kept patients 
awake all night before operation, has 
almost disappeared and the barbarous prac- 
tice of purging on the third post-operative 


Rives — Post-Operative Treatment 


45 


day has lost much ground, but the early 
enema and flush are strongly entrenched 
and yield slowly, if at all. Peristalsis is 
arrested by handling the bowel or perito- 
neum. This paresis is a protective and 
salutary condition and no attempt should 
be made to correct it. It is useless to do 
so for the disturbance of the intestine’s 
peaceful rest results only in a peevish, re- 
sentful and disordered response that not 
only fails to empty it effectively, but 
causes its unfortunate owner infinite dis- 
tress. This churning of stagnant bowel 
contents acts much as a similar process 
would on beer. If tympanites was not 
present, it is produced ; and if it was 
present, it is increased and prolonged. If 
the colon was properly emptied before 
operation, there is no need for concern 
about bowel movement. A brief period of 
constipation does no harm and the disturb- 
ance of rest incident to repeated enemas 
and flushes before orderly peristalsis is 
resumed is a serious matter. We have 
practiced studious neglect of the bowel for 
many years with much satisfaction to our- 
selves and our patients, though some of 
them are distressed by the absence of gas 
pains. Tympanites and abdominal colic are 
due to intestinal trauma and may be largely 
avoided. If they occur, hot stupes and a 
rectal tube to save effort in expelling gas 
give more relief than any other measures. 
Orderly peristalsis is resumed on the third 
or fourth day after which daily enemas 
will give good results and will suffice for 
all ordinary needs. 

Care of the wound is very simple, if 
properly carried out. Frequent dressing 
of a clean wound is needless and a great 
nuisance to the patient. If no drains have 
been left in and infection or hemorrhage 
do not occur, there is no need to change 
the dressing before the sutures are re- 
moved. However, one change two or three 
days after operation may be worth while 
if the gauze become badly stained with 
serum and blood from the incision, for this 
makes the dressing stiff and uncomfortable. 
Sutures may be removed on the eighth day. 


for at that time union has become fibrous. 
After removal the skin should be cleaned 
with alcohol or ether and a dry dressing 
applied. It is well to inspect again in two 
or three days for separation of the skin 
sometimes occurs. Sudden sharp pain in 
a wound usually means that a hematoma 
has developed. This should be evacuated 
and bleeding controlled. Pressure is usually 
sufficient. Careful inspection for possible 
wound rupture must be carried out. Rup- 
ture usually announces itself by a gush of 
blood stained fluid, but if the skin remains 
intact pain or the nausea incident to stran- 
gulation of bowel or omentum may be our 
only warning. Complete resuture of the 
wound should be done at once, preferably 
by through and through non-absorable 
sutures. The immediate result is almost 
always excellent, but we have not been so 
fortunate as Lahey in avoiding incisional 
hernia. 

Fever persisting after the third day 
should cause careful inspection of the in- 
cision for evidence of infection. Redness, 
local heat and induration point the way to 
the focus. No instrument is so valuable 
for examination as the ungloved fingers. 
Areas of induration require opening with a 
blunt instrument. If pus is found, it is 
usually best to remove the adjacent suture, 
make a free opening and treat the entire 
area with hot wet compresses. I prefer a 
saturated magnesium sulphate solution, 
since it adds a hygroscopic action to the 
more essential heat. This simple treat- 
ment clears up simple stitch infections in 
two or three days. When extensive in- 
volvement of fat and fascia is present, the 
wound must be opened widely and treated 
either in the same manner, or by the Car- 
rel-Dakin technique. The latter is best if 
properly carried out, but quite worthless 
otherwise, and it is very difficult to use in 
most hospitals. Antiseptics are quite 
worthless, unless they destroy the slough 
and exudates that protect the rear of the 
advancing army of bacteria. I know of no 
antiseptic that accomplishes this except 
Dakin’s solution. 


46 


Rives — Post-Operative Treatment 


A policy of studious neglect of wounds 
pursued for nine years has been accom- 
panied by an incidence of wound infection 
less than 2 per cent. Sealing of the defect 
with fibrin occurs in twelve hours and in- 
fection will not occur if we do not pry into 
it. Brilliant and seductive colors painted 
on the skin serve only to produce an an- 
noying dermatitis. 

It is not my purpose to deal with the 
serious complications incident to operative 
surgery, but it seems necessary to consider 
a few that are so common as to force 
themselves on our attention. 

A slight degree of shock attends all 
major operations and is unavoidable, but 
severe shock following ordinary operations 
indicates a poorly planned, poorly executed, 
or ill advised operation. It must be borne 
in mind that there are only three measures 
of proven value in the treatment of shock; 
namely, external heat, rest, and fluids, in- 
cluding glucose solutions and blood. Stimu- 
lants have never shown results experimen- 
tally, nor in our hands clinically. Strych- 
nin interferes with the salutary effect of 
morphine and should be avoided. I have 
never seen evidence of improved heart 
action from digitalis, though I must admit 
that I have never seen it given in dosage 
large enough to accomplish anything. A 
diseased heart needing digitalis should 
have it before operation and a normal 
heart will show no benefit from its use. 

Fluids may be given by rectum, by hypo- 
dermoclysis and by vein. The three 
methods differ only in the rapidity with 
which results may be obtained. Infusion 
is the most certain, the most rapid and 
produces the least discomfort. I believe 
that glucose and sodium chloride are the 
only substances worth adding to water for 
infusion. It is well to remember that there 
is a limit to the amount of fluid that may 
be given with benefit, and that in mild de- 
grees of shock, external heat and rest will 
give the desired result with a very moder- 
ate amount of fluids, the administration of 
which interferes seriously with rest. 


Morphin should be given to the point of 
maximum therapeutic effect with little re- 
gard for the dose required, for in the 
absence of rest and relief of pain all other 
measures will fail. 

Nausea follows almost all abdominal 
operations and vomiting follows a great 
many. It is due to many causes, most im- 
portant of which are the central effect of 
the anesthetic and intra-abdominal trauma. 
For nausea and vomiting in the first three 
or four hours nothing need be done, ex- 
cept the application of cool compresses to 
the throat and face. There is no need to 
withhold cracked ice and ice water in small 
quantities at this time. They are very 
grateful to the patient and do not increase 
the trouble. It is much less trying to 
vomit something tangible than to retch 
without effect. If the condition persists 
stomach washing should be performed 
without delay. It is by far the most effec- 
tive measure and should not be delayed 
until serious gastric dilatation has oc- 
curred. In obstinate cases a duodenal tube 
should be passed into the stomach through 
the nose and left in place thus providing 
constant drainage of the stomach and a 
ready avenue for frequent gastric lavage. 
Frequent vomiting of small quantities of 
bile stained fluid indicate acute dilatation 
of the stomach, or paralytic ileus of the 
small gut. The consideration of these 
would lead us too far afield as would also 
the late appearance of nausea and vomit- 
ing, usually with abdominal pain and dis- 
tention that heralds post-operative intes- 
tinal obstruction. Simple nausea may be 
relieved frequently by sips of hot salty 
broth, or of ice cold brine, and, as men- 
tioned before, late simple nausea some- 
times responds to a small feeding of dry 
food. The condition is not due to the con- 
tents of the stomach, and we believe that 
it is a mistake to withhold fluids. No re- 
lief is obtained by so doing and a burden 
of intolerable thirst is added to the patient’s 
load. Fluids by other routes never relieve 
thirst completely. 


Rives — Post-Operative Treatment 


47 


Retention of urine is very frequent. I 
believe I have left it to the last, because 
I can formulate no satisfactory policy for 
its management. A hot water bottle over 
the bladder, hot irrigation of the perineum, 
hot enemas, the sound of running water, 
spirits of nitrous ether and voodo incanta- 
tions may be tried and will sometimes be 
followed by relief. None of them has half 
the value of letting the patient sit up or 
stand and leaving him to his own devices, 
but unfortunately this is not -without risk. 
Catheterization is frequently required and 
opinions vary as to when it should be done. 
The more frequently it is performed, the 
greater is the risk of infecting the Madder 
from without, and the longer it is delayed 
the greater the risk of infection, due to 
atonic dilatation of the bladder and conse- 
quent stagnation of urine. Our conclusion 
must depend on who is to do the catheteri- 
zation. With meticulous aseptic technique, 
the bladder is seldom infected from with- 
out and probably the instillation of a non- 
irritating antiseptic, such as mercuro- 
chrome, after the process lessens the risk. 
If such precautions are observed, it is 
probably best to empty the bladder when- 
ever it is sufficiently full to produce real 
discomfort. 

CONCLUSION. 

You will note that we offer noth- 
ing original. The principles governing 
our conduct of a case were well established 
ten years ago, and there are more than 
enough procedures in common use to deal 
with any need. It is not hard to treat 
patients after operation, but it sometimes 
takes real courage not to over treat them. 
We feel that it is best to treat only for 
definite indications. I have considered only 
those indications common to almost every 
case. If the don’ts seem to preponderate, it 
is because I feel that the prevailing ten- 
dency is to over treat simple cases. Every 
surgeon should be master of all resources 
for protection of his patient, but he should 
weigh carefully the advantages and disad- 
vantages of every measure in the indi- 
vidual case at hand. If this be done, I am 


confident that less energy will be expended 
to no purpose and many troubled bodies 
will spend their nights in sleep. 

DISCUSSION. 

Dr. 0. C. Cassegrain (New Orleans) : After 

listening to Dr. Rives splendid resume of post- 
operative treatment, to me his apology for the 
choice of such an every-day subject is out of place. 
Instead, I congratulate him, for I have always felt 
that it is attention to details, at times apparently 
trivial, which frequently makes the difference be- 
tween an easy or a bad convalescence, between 
success and failure. 

The two most common causes of post-operative 
discomfort are undoubtedly gas pains and nausea, 
and while not dangerous per se, they are certainly 
very important and a source of great concern to 
the patient. By following the plan outlined by 
Dr. Rives we can keep down these complications 
to a minimum. 

Nine years ago, in an effort to lessen the in- 
cidence of post-operative gas pains, we divided 
our service into two sections. The patients in 
one section were purged the day or night before 
operation, while those in the other were not 
purged. It was striking to see how much more 
comfortable and free from gas pains were the 
patients who had received no purgative before 
operation. 

Dr. Rives views on the question of post-opera- 
tive purgation coincide with mine. In our service 
the purgative is usually given on the seventh 
day after operation; but an enema is given on 
the third day and sometimes on the second day. 

Dr. Alton Ochsner (New Orleans) : There are 

just a few points which Dr. Rives mentioned that 
I would like to emphasize; first, post-operative 
pulmonary complications. There is no doubt that 
aspiration is responsible for most of these cases, 
not only when the operation is done under gen- 
eral, but also where local is employed. We had 
occasion two years ago to examine five patients 
who had been prepared for tonsillectomy by in- 
jecting the peritonsillar structures with one-half 
per cent of novocain solution. These patients were 
then given iodized oil to swallow. In all the cases 
the oil passed in to the trachea instead of the 
esophagus, demonstrating that aspiration does 
occur under local anesthesia. 

As routine, where there is abdominal distension, 
we have been using turpentine stupes applied to 
the abdomen in our abdominal cases. As Dr. 
Rives brought out, if the use of stupes is contra- 
indicated, and where the patient has gas pains, 
we use the therapeutic light, which does not inter- 
fere with the dressings and relieves the patients 
completely. 


48 


Rives — Post-Operative Treatment 


Now the question arises: What should be done 

with post-operative urinary retention? These 
patients should be catheterized. If catheterization 
is carried out we are not apt to produce cystitis 
in a healthy bladder. Cabot has shown that 
catheterization should be done early and one 
should not wait longer than a period of eight 
hours; if this is carried out we see few cases 
of cystitis. Dr. A. J. Ochsner, in those individuals 
not able to urinate, instilled two ounces of glycer- 
ine into the bladder, which procedure invariably 
gave good results. 

Dr. Marcy J. Lyons (New Orleans): Dr. Rives 

mentioned that he was dealing only with uncom- 
plicated cases, but I would like to get information 
from him as to how to circumvent an impending 
paralytic ileus. This condition, of course, we do 
not recognize until three or four days after the 
operation, when vomiting and distention occur, 
and repeated enemas return clear. I have had 
two or three sad experiences, the last a case 
in which a simple bilateral salpingectomy, sus- 
pension of the uterus and appendectomy was done. 
This patient took a rather difficult anesthetic and 
a good deal of manipulation of the bowel was 
required. She vomited from the time she was oper- 
ated on, and could not even retain liquids, which 
were given in small quantities. Protoclysis was in- 
stituted and after being retained for a period of 
several hours, expelled all at one time. About the 
second or third day she showed some little disten- 
tion. The vomiting continued and the distention 
increased. About the fifth day, after having given 
several enemas, pituitrin, etc., all of which re- 
turned clear, I ordered a purgative in the hope 
that peristalsis might be restored, and as a last 
resort, but to no avail. She had a rapid pulse all 
the way through. 

Now I am wondering if the free administration 
of morphin might not be conducive to a paralytic 
ileus in certain cases? While thoroughly agree- 
ing in the use of it, I believe that in some cases, 
especially in those case that give a history of ob- 
stinate constipation, and where must manipulation 
of the bowel is necessary, it might be well to 
reduce the amount of morphin to a minimum. 

Dr. Rives (closing) : I have avoided discussion 

of paralytic ileus as being too big a subject to 
take up under post-operative treatment. In an- 
swer to Dr. Lyons I would say that ileus like 
“gas pains” is best treated by prevention. If 
peritoneum and viscera are handled as little and 
as gently as possible this complication will be 
very infrequent. 

The treatment consists not in attack on the 
gut itself but in supporting the patient until in- 
testinal paresis is spontaneously relieved and or- 
derly peristalsis resumed. Ignore the ileus and 
keep the patient alive. Water and glucose must 
be supplied, preferably by hypodermoclysis or in- 


fusion, in large quantity. Five to ten thousand 
c.c. of 5 per cent glucose every 24 hours is re- 
quired, for the fluid loss is usually very great. 
There is reason to believe that the pancreas does 
not supply a normal amount of insulin at such 
times and clinically the addition of this substance 
seems to improve results. Half the amount neces- 
sary to burn the amount of sugar given is the 
usual dose. This measure has been criticized as 
being irrational but ileus of this type seems to 
have its origin in the autonmic nervous system 
and the pancreas receives its nerve supply from 
the same plexus. 

In addition to the supply of food and fluids 
the acid-base equilibrium must be maintained. 
Haden and Orr have demonstrated that this is 
best accomplished by keeping the blood chlorides 
at the normal level. They found that when this 
is done dogs with high intestinal obstruction may 
be kept alive as long as 21 days. We find that 
in most cases 1 per cent sodium chloride added to 
the glucose solution is sufficient but 2 per cent 
may be required in some cases. One case of my 
own lived with a complete small gut paresis due 
to mesenteric thrombosis for six days before 
peristalsis was resumed. Within 12 hours he 
seemed as well as a patient who had had an un- 
complicated severe operation three or four days 
previously. This is a very valuable addition to 
the therapy of intestinal paresis and deserves 
wider use. 

Stomach drainage and washing is of distinct 
value and is universally used. Enterostomy has 
had very wide use and is supported by the best 
authorities. I have been a strong advocate and 
still am in cases of mechanical obstruction, but 
my faith has been shaken. Enterostomy into a 
paralyzed gut is useless. It will not drain until 
peristalsis has been resumed and then it is not 
needed. If it is to have value it must be done 
above the involved gut in a portion still showing 
active peristalsis. This is always difficult and 
may be impossible due to the crowding of the 
diseased bowels into the wound. The search for 
active gut may easily do serious harm. 


O’lodoxybenzoic Acid in Treatment of Infectious Ar* 
thritis. — 0-iodoxybenzoic acid in the treatment of infec- 
tious arthritis, accordng to Stein and Taube, New York, has 
three main actions: (1) analgesia, (2) relief of muscle 

spasm, and (3) reduction of swelling. Of the series of 
102 patients reported on, two with acute rheumatic fever 
were treated by rest in bed plus the administration of the 
drug. All the others were ambulatory. Ane hundred cubic 
centimeters of a fresh 1 per cent solution was injected into 
the vein of each arm arternately every three days and the 
solution was allowed to run in by gravity. The authors 
used amiodoxyl benzoate-Abbott. — J, A. M. A., 90:1608- 
1610. 1928. 


Castellani — Tropical Dermatomy coses in New Orleans and La. 


49 


TROPICAL DERMATOMYCOSES IN 
NEW ORLEANS AND 
LOUISIANA*! 

ALDO CASTELLANI, M. D., 

New Orleans. 

The principal dermatomycoses which are 
usually considered “tropical” are the fol- 
lowing ; 

1. Tinea cruris (Dhobie itch, Epider- 
mophytosis) . 

2. Dermatitis interdigitalis mycotica 
(Mango toe). 

3. Mycotic pomphylix. 

4. Pruritus ani of mycotic origin. 

*Read before Louisiana State Medical Society, 
!^ew Orleans, April 26-28, 1927. 

tFrom the Department of Tropical Medicine, 
rulane University of Louisiana. 


5. Intertrigo saccharomycetica. 

6. Tinea albigena. 

7. Tinea imbricata. 

8. Tinea intersecta. 

9. Blastomycosis. 

10. Sporotricosis. 

11. Accladiosis. 

12. Mycetoma. 

13. Paramycetoma. 

14. Pseudomycetoma. 

15. Tinea flava. 

16. Tinea nigra. 

17. Pinta. 

18. Tinea capitis tropicalis. 

19. Tinea barbae tropicalis. 

20. Tinea unguium tropicalis. 

21. Piedra. 

22. Tricho-aspergillosis. 

23. Trichomycosis axillaris flava, ru- 
bra, nigra. 


CLASSIFICATION OF TROPICAL DERMATOMYCOSES 


1. Due to fungi of the genus 
^pidermophyton Lind, 1879, 
'richophyton Malmsten, 1845, 
licrosporum Gruby, 1843. 


Ep. c^Ws Castellani, 1905, common variety of Tinea cruris (dho- 
bie itch). 

Ep. perneti Castellani, 1907, variety of Tinea cruris 
Ep. rubrum Castellani, 1909, variety of Tinea cruris. 

T. nodoformans Castellani, 1911, variety of Tinea cruris. 

T. macfadyeni Castellani, 1905, variety of Tinea alba. 

T. albiscicans Nieuwenhuis, 1907, Tinea albigena. 

T. blanchardi Castellani, 1905, Tinea s abouraudi tropicalis. 

T. ceylonense Castellani, 1908, Tinea nigrocircinata. 

T. soudanense Joyeux, 1912. 

T. violaceum Bodin, 1902. 

T. decalvans Castellani, 1911. 

T. currii Chalmers and Marshall, 1914. 

T. discoides Sabouraud, 1909. 

T. violaceum Bodin, 1902, var. khartoumense 
Chalmers and McDonald, 1915. 

T. polygonum Uriburii, 1909. 

T. exsiccatum Uribuni, 1909. 

Microsporum flavescens P. Horta, 1912, variety of Tinea capitis and 
corporis. 

T. louisianicum Castellani, 1926. 

T. spiculatum Castellani, 1927. 


«H tg 

m "p, 
« as 

V “ 

<u 

ra C 
>.5 


II. Due to fungi of the ( En. trojncale Castellani, 1914. Tinea imbricata. 
enus^ Endodemwphyton Cas- j En. indicum Castellani, 1911, Tinea imbricata. 
illani, 1909. ( En. castellanii Perry, 1907, Tinea intersecta. 


eJ?s i£?ass2m ^Sniom^sS \ Castellani, Tinea flava. 

IV. Due to fungi of the ( C. mansoni Castellani, 1905, Tinea nigra, 
enus Cladosporium Link, 1809. / C. madagascariense Verdun, 1913, peculiar nodular affection. 


50 


Castellani — Tropical Dermatomy coses in New Orleans and La. 


CLASSIFICATION OF TROPICAL DERMATOMYCOSES— Continued 


V. Due to fungi of the 
genera Saccharomyces Meyen, 
1838, Cryptococcus Kiitzing, 
Blastoviycoides Castellani, 1926, 
Monilia Persoon, 1797. 


Several species, some of which in- 
completely investigated. 


I Varieties of blastomycosis. 


VI. Due to fungi of the 
genus Nocardia Toni and Trev- 
isan, 1889, and Cohnistrepto- 
thrix Pinoy, 1911. 


N. minutissima Burchardt, 1859, erythrasma. 

N. carougeaui Brumpt, 1910, juxta-articular nodules. 

N. rivierei Verdun, 1912, nodular affection. 

C. tenuis Castellani, 1912, trichomycosis axillarum. 

C. thibiergei Pinoy and Ravaut, 19tl9, nodular affection. 


VII. Due to fungi of the 
genera Sporotrichum Link, 
1809, Hemispora Vuillemin, 

1906, Enantiothamnus Pinoy, _ 
1911, Scopulariopsis Bainier, " 

1907, Cladosporium Link, 1809, 
Acremonium Link, 1809, Acla- 
dium Link, 1809. 


VIII. Due to fungi of the 
genera AspergiUus Micheli, 
1725, Sterigmatocystis Cramer, 
1869, Madurella Brumpt, 1905, 
Indiella Brumpt, 1906, Nocar- 
dia Toni and Trevisan, 1889, - 
Cohnistreptothrix Pinoy, 1911, 
Sporotrichum Link 1806, Mon- 
osporium Bonorden and Sac- 
cardo 1898, Glenospora Berkley 
and Curtis 1876. 


Sporotrichum beurmanni Matruchot and 
Ramond, 1905. 

S. schenki Hektoen and Perkins, 1900. 

S. asteroides Splendore, 1911. 

S. indicum Castellani, 1908. 


Varieties of sporotri- 
chosis found in the 
tropics. 


Hemispora stellata Vuillemin, 1906. 
Enantiothamnus braulti Pinoy, 1912. 
Scopulariopsis blochi Matruchot, 1911. 
Clddospomum madagascariense Verdun, 
1913. 

Acladium castellanii Pinoy, 1916. 


Various types of gum- 
" matous and ulcera- 
tive affections. 


Aspergillus bouffardi Brumpt, 1906. 

Sterigmatocystis nidulans Eidam, 1883. 

Madurella mycetomi Laveran, 1902. 

M. bovoi Brumpt, 1910. 

M. tozeu-ri Nicolle and Pinoy, 1906. 

Indiella mansoni Brumpt, l906. 

7. reynieri Brumpt, 1906. 

7. somaliensis Brumpt, 1906. 

Nocardia madurae Vincent, 1894. 

N. asteroides, Eppinger, 1890. 

N. pelletieri Laveran, 1906. 

N. bovis Harz, 1877. 

C. israeli Kruse, 1896. 

Sporotrichum Schenki Hectoen and Perkins, 1900. 
Monosporium apiospermum Saccardo, 1911. 

Glenospora khartoumensis Chalmers and Archibald, 1916. 
G. semoni Chalmers and Archibald, 1917. 


A 

s 

o 

>> 

S 


<a; 

> 


IX. Due to fungi of the barbae Castellani, 1907, Aspergillosis of hairy parts. 

1 onn I P- barbae Castellani, 1907, Penicilliosis of hairy parts. 

1727, Penicillium Link, 1809. ^ 

i Aspergillus Micheli, 1725. 

Penicillium Link, 1809. 

Monilia Persoon, 1791. 

Montoyella Castellani, 1907. 

XL Due to fungi of the ( T. giganteum Behrend, piedra. 
genus Triehosporum Behrend, ^ ^ i Tropical varieties of nodular 

1890. I Species as yet not well determined. ^ trichomycosis. 

XII. Due to fungi of the c 

genus Pityrosporum Sabouraud, 1 Pityrosporum cantliei Castellani, variety of tropical seborrhoea. 

1903 . ( 


^ Pinta. 


Castellani — Tropical Dermatomycoses in New Orleans and La. 


51 


It should be clearly stated that dermato- 
mycoses “tropical,” in the strict sense of 
the word, are exceedingly few, as exceed- 
ingly few are internal diseases which can 
be called “tropical” sensu stricto. In a 
general way one may say that tropical dis- 
eases are merely diseases which are more 
frequently met with in the tropics than in 
the temperate zone. 

What are the tropical dermatomycoses 
most common in New Orleans and Louisi- 
ana? I wish to state at once that my re- 
sults are based not only on my own ex- 
perience but on the researches and ex- 
perience of men who have practiced in this 
country for many years, principally Pro- 
fessor Menage and Professor Hopkins, 
among others, and I should like to express 
my indebtedness to them for their generos- 
ity in placing their results at my disposal. 

TINEA CRURIS (EPIDERMOPHYTOSIS). 

This is well known as an extremely com- 
mon condition in New Orleans, Louisiana, 
and all Southern States, especially in the 
spring, the summer and the autumn. In 
recent years it has become common in the 
Northern States and all over the Continent. 
It is so common that there is no need of 
describing it; the patches generally situ- 
ated in the inguinal region with the well- 
marked festooned border are typical. 

Among the fungi I have isolated in these 
cases in New Orleans are the following: 
Epidermophyton ruhrum, Epidermophyton 
cruris, Trichophyton nodoformans, Tricho- 
phyton spiculatum. T. spiculatum is char- 
acterized by the presence of numerous 
spicules on the surface of the growth. 

DERMATITIS INTERDIGITALIS EPIDERMOPHYTICA. 

This is a localization of epidermophyton 
and trichophyton infections in the toes. It 
is extremely common in this country. 

In certain cases it may be considered to 
be a very serious disease. The seriousness 
of the condition is caused not by the fun- 
gus per se but by the secondary bacterial 
invasions. It is not at all rare to find a 
strepl^coccus infectio{n engrafted on the 


epidermophytic condition — and this strep- 
tococcus infection may give rise to a 
localized painful dermatitis with presence 
at times of bullae; or it may give rise to 
an erysipelas-like condition; it may give 
rise to a lymphangitis with inguinal aden- 
itis and in the Tropics I have seen cases of 
generalized streptococcus infection arising 
in this way; repeated attacks of strepto- 
coccus inflammation at times cause at first 
permanent edema then a fibroid thickening 
of tissues indistinguishable from elephant- 
iasis. 

MYCOTIC POMPHY.LIX. 

This type of epidermophytosis is very 
common in New Orleans and of difficult 
cure. 

PRURITUS ANI OF FUNGAL ORIGIN. 

For some years I called attention to a 
type of pruritus ani, which is of fungal 
origin. The patient complains of very 
severe pruritus, not as a rule continuous, 
but at intervals. The pruritus is often 
worse at night, but the attacks of unbear- 
able itching may come on at any time. The 
inspection of the ano-perineal region in 
very recent cases may reveal nothing at all 
except, perhaps, signs of scratching, but 
in most cases, on careful examination, 
minute, red, slightly raised, infiltrated 
patches may be seen in the perianal regian, 
occasionally arranged into two curved 
lines. In a number of old cases signs of 
dry or moist eczematous dermatitis are 
present, and streptococcus and other sec- 
ondary bacterial infection may become very 
heavy. If many coli and proteus bacilli 
are present, the fungus may disappear com- 
pletely or become extremely scarce. 

With regard to treatment, an antimyco- 
tic ointment often answers well. My old 
dhobie itch ointment may be used, consist- 
ing of sulphur gr. 30, salicylic acid gr. 30, 
vaseline one ounce, or Deeks’ ointment, 
may be employed, and is very often suc- 
cessful. Whitfield’s ointment, to which 2 
per cent carbolic acid has been added, is 
very useful. A fuchsin resorcinal paint 
is also useful. In very obstinate cases 


52 


Castellani — Tropical Dermatomy coses in New Orleans and La. 


roentgen-ray therapy is beneficial. For 
more details on pruritus ani of fungal 
origin the reader is referred to my previ- 
ous publications on the subject, among 
which is “Pruritus Ani and Pruritus Vul- 
vae of Fungal Origin,” New Orleans Medi- 
cal and Surgical Journal, pp. 625-633, vol. 
79, No. 9, March, 1927. 

INTERTRIGO SACCHAROMYCETICA VEL 
CRYFTOCOCCICA. 

Some years ago in Ceylon I described a 
type of intertrigo usually affecting the in- 
guinal region but occasionally other 
regions, armpits, etc., in which a large 
number of yeast-like fungi were found. I 
grew a yeast-like fungus which I called 
S. samboni; later cryptococci monilias and 
debaryomyces fungi. The condition at first 
is characterized by the presence of an ery- 
thematous, round or oval patch in each cru- 
roinguinal region; the patch rapidly en- 
larges and sometimes may become fes- 
tooned. In a later state slight exudation 
may take place and even a true eczematoid 
dermatitis may develop. Occasionally a 
few white spots or patches may be seen 
which can be fairly easily removed; these 
consist of masses of the fungus. With re- 
gard to treatment I have found glycerine 
of borax (B. P.) diluted with rose water 
useful ; also the application of a 2 per cent 
permanganate of potassium lotion, or di- 
luted Tr. Ladi. 

Two types of intertrigo saccharomyce- 
tica infection may be distinguished. 

The primary, as described above ; the sec- 
ondary, in which the saccharomycetic or 
cryptococcus infection develops on epider- 
mophytic lesions. 

TINEA ALBIGENA. 

This condition was first observed in Java 
by Nieuwenhuis. It commences on the 
palms or soles but may extend upward to 
the forearms and legs, or downward to 
the nails. At first it appears as small itchy 
spots on which bullae appear which burst 
leaving a desquamating, itching tender 
area. In course of time a diffuse hyper- 


keratosis forms in which deep fissures indi- 
cate the natural folds, while horny semi- 
detached rings surround the sweat orifices. 
It is very chronic and in course of time 
leads to a depigmentation of the affected 
areas which appear like leucoderma patches. 
This condition is permanent. I have seen 
two cases of a somewhat similar condition 
due to epidermophytosis in New Orleans. 

Treatment . — Apply tincture of iodine, or 
Whitfield’s Ointment, or a 1-5 per cent 
chrysarobin ointment. 

TINEA IMBRICATA. 

This dermatomycosis which is so common 
in the Far East and certain islands of the 
Pacific, seems to be absent from Tropical 
America. The disease is of great interest 
clinically and etiologically. Clinically, the 
term tinea applied to it is hardly correct, 
as the condition is totally different from 
the usual trichophytoses and epidermophy- 
toses. 

The development of the eruption is very 
interesting. A small, initial brownish spot 
appears, generally on the arms, chest or 
back. After a few days this spot splits in 
the center, and in this way a ring of large, 
flaky scales is formed, with their bases at 
the periphery of the lesion; this scaly ring 
expands peripherally, and while it does so, 
another brownish spot appears in the cen- 
ter, at the same site as the first brown spot ; 
this new brown patch also breaks in the 
center, and in this way a second scaly ring 
is formed inside the second ; and so on, un- 
til a number of scaly rings are developed. 

Manson aptly compared this development 
of concentric rings to the concentric rip- 
ples produced by a pebble thrown into a 
pool of water. 

In very many cases however the eruption 
becomes diffuse and no rings are seen. The 
scales are flaky, tissue-paper-like, of large 
size, up to 1/^ inch in length, dry, and of a 
dirty greyish, or brownish color. In my 
experience, the fungus never invades the 
hair follicles, but it often invades the nails. 


Castellani — Tropical Dermatomycoses in New Orleans and La. 


53 


TINEA INTERSECTA. 

The eruption begins as small, roundish 
or oval dark brown pruriginous patches 
generally situated on the arms, legs, chest 
or back. The surface of these patches is 
darker than the surrounding skin with 
a border composed of minute black pa- 
pules. Later the tense surface dries, 
shrivels and cracks, producing white 
lines ntersecting the dark brown patch. 
Later, when the cracks deepen, curled- 
up scales, white internally and brown 
externally, appear. When these scales 
are removed white patches are left. The 
brown patches may remain isolated or 
may fuse together, forming large irregu- 
lar areas. At times some patches may dis- 
appear spontaneously. 

The health of the patient is never af- 
fected, but there may be a slight eosino- 
phi'lia. 

BLASTOMYCOSIS. 

The term blastomycosis covers a group 
of affections caused by yeast-like fungi. 
The botanical description of these fungi I 
have given in previous papers, and it may 
be found also in Castellani and Chalmers' 
Manual of Tropical Medicine, third edition, 
chapters on fungi. Here it may be suffi- 
cient to mention a simple classification I 
have introduced for the use of clinical path- 
ologists : 

Of blastomycoides (blastomyces) there 
are certainly several species. By using 
mannitol and lactose agar three fungal 
types can be differentiated fairly easily: 
immitis type, dermatitidis (or Gilchristi) 
type, tvlanensis type. After two to three 
weeks at 26° the cultures of the immitis 
type are slate black on mannitol, greyish on 
lactose; the cultures of dermatitidis are 
greyish occasionally slate black on manni- 
tol, dark brown or slate blackish on lactose ; 
the cultures of tulanensis are white both on 
mannitol and on lactose. The fungi should 
be grown in large tubes. 

I have suggested the following clinical 
classification of the various types of blas- 
tomycosis : 


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54 


Castellani — Tropical Dermatomy coses in New Orleans and La. 


1. Blastomycosis, Gilchrist type, very 
commonly found in this country, in Africa, 
in Asia, very seldom in Europe, character- 
ized by the presence of the well known ele- 
vated warty patches with micro-abscesses 
or well defined oval or round ulcers with 
granulating or papillomatous fundus, and 
violaceus border. 

2. Blastomycosis, W ernike-Posadas type 
(Coccidioides type). In addition to the 
warty or fungating patches deep destructive 
ulcerative processes develop. It is prin- 
cipally found in South America where the 
condition often affects the oral mucus and 
pharynx. Cases have been found in Cali- 
fornia. 

3. Blastomycosis sinus forming type 
(Blastomycosis glutealis). This generally 
attacks the tissues of the buttock and is 
characterized by the presence of numerous 
sinuses. It is found in Egypt, Ceylon, 
China. 

4. Blastomycosis, furunctdosis type. 
Clinically this is indistingushable from se- 
vere furunculosis. It often affects the scalp 
producing a suppurative folliculitis (folli- 
culitis cryptococcica decalvans). The yeast- 
like fungi found in this type probably be- 
long to the genus monilia (see Gehrman 
Lectures/ for 1926, University of Illinois). 

The types I have so far found in New 
Orleans are. 1. Gilchrist type, several cases. 
2. Furunculosis type, one case. I saw a 
typical case of the coccidioides type in Chi- 
cago last year — ^thanks to the kindness of 
Professor Davis of the Illinois University. 

SPOROTRICHOSIS. 

This dermatomycosis, although consid- 
ered to be tropical by several authorities, 
was, as well known, described first in Amer- 
ica by Schenk. The invading organisms 
may produce in the skin: 

(1) A sporotrichic chancre and lymph- 
angitis; this is the localized form. 

(2) A series of disseminated gummata. 

(3) A series of disseminated ulcers, 
some resembling syphilitic lesions, other 


tubercular, or furuncular, and others ech- 
thymatous. 

In additon the fungi may invade the in- 
ternal organs and cause lesions in mucous 
membranes, bones, joints, muscles and 
vscera. I have seen several cases in Europe, 
India, Central America and in Chicago but 
so far not in New Orleans. 

ACLADIOSIS. 

All over the body may be seen sharply 
defined, roundish or oval ulcers with red 
granulating cases with or without a puru- 
lent secretion which dries into thick yellow 
crusts. In addition, gummata-like nodules 
and boil-like lesions may be seen, and en- 
largement of the superficial lymph glands 
may be observed. Sometimes the blood 
shows a slight eosinophilia. Cases with 
purulent secretion show leukocytosis and 
suffer from fever at night. This condition 
first described by me in Ceylon some years 
ago has not yet been described in America. 
It is caused by a fungus of the genus Acla- 
dium : A castellanii Pinoy. 

MYCETOMA. 

Mycetoma, Madura foot, is characterized 
by the presence of granulomatous nodules 
and of sinuses in the foot, occasionally in 
other regions of the body. From the 
sinuses a certain amount of pus exudes 
which contains granules of different color, 
white, yellow, red, black. Madura foot, 
though rare, occurs in this country. Cases 
have been described by several observers. 

PARAMYCETOMA. 

Paramycetoma is clnically identical with 
mycetoma, but in the pus no granules are 
found, the fungi causing paramycetoma 
not producing sclerotia. 

PSEUDO MYCETOMA. 

Pseudo-mycetoma is clinically very sim- 
ilar to true mycetoma, the foot being de- 
formed and presenting numerous nodules 
and occasionally sinuses, but the condition 
is not of fungal origin. Very often it is a 
late manifestation of yaws. 


Castellani — Tropical Dei'matomy coses in New Orleans and La. 


55 


TINEA FLAVA. 

This condition is characteri'zel by the 
presence of bright yellow, roundish or oval, 
patches on the skin of the face, neck, chest 
and abdomen and arms. A very large num- 
ber of the natives of the low country of 
Ceylon and of many other tropical coun- 
tries, are affected. Sometimes the patches 
coalesce, giving rise to the diffuse form of 
the disease. Occasionally, in Ceylon and 
Southern India, one is surprised to see a 
Singalese or Tamil native with the face, 
chest and trunk of much lighter color than 
those of the other natives. On closer ex- 
amination it will often be found that the 
apparently light color of the skin is merely 
due to a diffuse form of a very light variety 
of tinea flava. Scrapings from the patches 
reveal presence of a fungus with the char- 
acteristics of a malassezia, and morpholog- 
ically very similar to the fungus found in 
pityriasi^ versico-lor o^f tempelrate z)ones. 
In fact, until recently tinea flava was con- 
sidered to be identical to tinea versicolor. 

I separated it from tinea versicolor for 
the following reasons: 

1. Tinea flava is of much lighter color. 

2. It affects the face more frequently 
than any other part of the body, while 
tinea versicolor is practically never found 
in that situation 

3. It is extremely chronic, developing 
in early childhood and lasting for life. 

4. It is difficult to cure, while tinea 
versicolor responds to treatment very 
readily. 

Tinea flava ‘occurs in New Orleans and 
Louisiana. 

TINEA NIGRA. 

This dermatomycosis is characterized by 
the presence of jet-black patches due to a 
fungus of the genus Chladosporium, which 
I called C. mansoni in honor of Sir Patrick 
Manson. This fungus is fairly easily grown 
on sugar media, giving rise to black colo- 
nies. In some tropical countries the 
condition s fairly common in natives, 
but may be found also in Europeans 


as shown by the following case : A 

European medical man went to Burmah 
from Ceylon for a pleasure trip. On com- 
ing back to Ceylon he noticed a roundish, 
very slightly elevated black spot on the 
palm of his left hand. This spot slowly 
increased in size for two months, becoming 
the size of a dime. A single applica- 
tion of formalin made it disappear, but 
three months later it reappeared. A 

second application of formalin cured the 
condition permanently. From the patch, 
before treatment, cultures were made and 
a chladosporium was isolated identical to 
the fungus found in native cases. 

CRYPTOCOCCOSIS EPIDERMICA. 

The condition is characterized by the 
presence on the arms, legs, chest and neck 
of roundish patches of a dirty yellow- 
brownish color. They consist of enormous 
numbers of blastomyces-like fungi of va- 
rious size, which have not yet been culti- 
vated. I saw a case in this country last 
year. 

Closely allied to this condition are cryp- 
tococcosis alba and cryptococcosis, rosia: in 
the former whiti|sh patches are found on 
the skin composed of enormous numbers of 
usually cultivable cryptococcus, saccharo- 
myces, debaryomyces, moniliie; in crypto- 
coccosis rosea, which is extremely rarie, 
budding organisms are found which on arti- 
ficial medica produce pink or red colonies. 

PINTA. 

Pinta is a disease common in Central 
America and certain parts of South Ameri- 
ca. It is characterized by patches on the 
skin of various color, yellow, black, bluish 
black, and white, leucodermic-like. As I 
have stated in previous publications the so- 
called yellow pinta is in ,all probability 
tinea flava. (See Journal of Tropical Medi- 
cine, London, January 1st, 1925.) 

TINEA CAPITIS TROPICALIS. 

It is interesting to note that in tropical 
countries ring worm of the scalp as a rule 
is less frequently met with than in the tem- 
perate zone. Certain types of tinea capitis 
are caused by the same fungi which cause 


56 


Castellani — Tropical Dermatomycoses in New Orleans and La. 


the condition in temperate climates. Cer- 
tain types, however, are caused by mycetes 
which apparently are seldom found outside 
the tropical belt. I will limit myself to de- 
scribing briefly the following two types: 
Tinea decalvans and tinea capitis due to 
T. louisianicum. 

Tinea decalvans. — This condition I de- 
scribed in Ceylon some years ago. Recently 
it has been found by Ota to be quite com- 
mon in China. In the first stage of the 
disease numerous patches are seen on the 
scalp covered with an enormous number of 
heaped up white scales. Later the scales 
disappear, the hair falls off and the patches 
remain bald permanently. The fungus I 
found in these cases I thought at first was 
a variety of Tidchophyton violaceum of 
Bodin, but Ota believes that it is a separ- 
ate species, at least biologically. The de- 
scription of this fungus (Trichophyton de- 
calvans) may be found in previous publi- 
cations of mine, among which the Gehr- 
mann Lectures, etc. It may also be found 
in Castellani and Chalmers’ “Manual of 
Tropical Medicine,” p. 2075. So far I 
have not found it in New Orleans. 

TINEA BARBAE TROPICALIS 

Tinea barbae is not very rare in New 
Orleans. Recently I saw a case from 
which a fungus was isolated very similar 
or identical to T. nodoformans which was 
first isolated in Ceylon. In this case my 
method of injecting ether and a mixture of 
absolute alcohol and ether in equal parts 
into the nodules induced a rapid cure. 

TINEA UNGUIUM TROPICALIS 

Two types can be separated, a type due 
to Epidermophyton, Trichophyton and En- 
dodermophyton fungi, and a type due to 
fungi of the genus Aspergillus and genus 
Penicillium. Cases of the latter type have 
been observed in various countries by 
Brumpt, Ota, Johns and myself. 

Tinea capitis due to Trichophyton lousi- 
anicum. — A type of trichophytosis not rare 
in New Orleans is one caused by the 
fungus which I have called Trichophyton 


louisianicum. The fungus may attack the 
scalp and hair as well as occasionally the 
glabrous regions. So far, I have seen it 
only in colored children. The lesions are 
generally superficial. One or several round- 
ish or oval patches denuded of hair are seen 
on the scalp, the surface is smooth or there 
may be some pytiriasic squammae, they are 
not limited as a rule by a raised border, no 
true “stumps” are seen. The fungus is sel- 
dom present in large amount: it may be 
found at times in scrapings from the patch : 
it may be present also in the hair in the 
intrafollicular portion inside or outside or 
both. When the glabrous parts — usu- 
ally the neck — are attacked, oval or 
roundish whitish patches are seen with 
pityriastic desquamation ; an interesting 
point is that at times a large number of 
yeast-like organisms are present in addi- 
tion to the trichophyton fungus, and it is 
quite possible that the white appearance of 
certain patches may be due to the presence 
of the yeast-like fungus; by mycological 
cultural methods both organisms may be 
grown; the yeast-like organism is grown 
much more easily than the trichophyton 
fungus. 

A moist variety caused apparently by 
the same fungus is also met with; in this 
variety the patches show thick crusts 
rather than scales and the condition may 
be mistaken with a form of seborrhoea on 
which a pyogenic infection has become en- 
grafted. As this fungus is very little 
known I may repeat here the description of 
its cultural characteristics. 

Acid glucose agar 4 per cent . — In fully devel- 
oped cultures three to six weeks old a fairly 
abundant growth is noted with a central white 
portion consisting of white duvet springing up 
from a rather hard mass; the peripheral portion 
of the growth is yellowish; the submerged portion, 
viz., the portion growing deep into the medium 
frequently shows one or two or several spots of 
reddish, or brownish-reddish color, the reddish 
color is usually absent in very young cultures. 
When large tubes are used and the medium is 
not dry, the growth often shows a beautiful bor- 
der of a deep yellow-reddish color, the color of 
the skin of a tangrin. 


Castellani — Tropical Dermatomy coses in New Orleans and La. 


57 


Acid gliLdose agar prepared with peptone water 
instead of broth. — The appearance of the growth 
is identical with that observed in cultures on glu- 
cose agar prepared with broth, but the yellow 
color is at times much more marked. 

Neutral glucose agar 1 or i- per cent. — Growth 
less vigorous; central white knob; periphery 
whitish or yellowish. 

, Casein Digest agar 3 per cent. — Growth fairly 
abundant, covered with white duvet — portions of 
submerged growth may be reddish or yellowish- 
reddish. 

Acid maltose agar 4 per cent (Sabouraud’s me- 
dium). — Appearance somewhat similar to that 
noted in glucose agar cultures, but growth less 
abundant and yellow color much less marked — or 
may be absent. 

Sabouraud’s medium (modified).- — This medium 
contains in addition to maltose a small amount of 
glycerine. The fungus grows well on it and the 
yellowish color is very evident. 

Gelatin agar. — Knobby growth, tending to be 
almost cereberiform, covered with white duvet — 
peripheral portion may be yellowish. 

Glycerine agar . — The fungus growth profuse- 
ly; the growth is white with at times a yellowish 
tinge. 

Gelatine. — The fungus slowly liquefies gelatine; 
usually liquefaction begins on the third or fourth 
day. 

Sugar media. — No gas is produced in any sugar. 
A slight amount of acidity is occasionally pre- 
sent in levulose and a few other sugars after 
three weeks incubation. 

Microscopical examination of preparation from 
cultures. — Until recently no “fuseaux” had been 
found but a few weeks ago they were found in 
some old cultures. They are elongated, fusiform 
structures with a number of septa. The apex 
does not show any hair-like process. Temporarily 
I have placed the fungus for convenience sake in 
the genus Trichophyton, section incertae sedis. 
With regard to macroscopic features, the fungus 
must be separated from the following organisms: 
Trichophyton sulphurem, Microsporum flavescens, 
Trichophyton ochraceum, Trichophyton flavum. 

In contrast to T. sulphureum there is no speckled 
appearance and the cultures are not crateriform; 
moreover in fairly old cultures reddish or brown- 
ish-reddish spots are often seen in the submerged 
growth; with regard to M. flavescens described by 
Horta in Brazil, 1912, it appears it was micro- 
scopically a typical microsporum fungus; with re- 
gard to macroscopic features, the whole growth 
including apparently the center was of a yellow 


color; Trichophyton ochraceum and Trichophyton 
flavum give rise to cerebriform colonies. 

PIEDRA 

This is a disease found in certain parts 
of South America and America, principally 
in Columbia. It is characterized by the 
presence of small hard nodules on the hair 
of the scalp. The nodules are composed of 
large numbers of mycelial spores of fungus 
belonging to the genus Trichosporum. 

ASPERGILLOSIS AND PENICILLIOSIS OF THE BEARD 

The hairs of the beard and mustache are 
covered with minute, dark-grayish, or 
black, or greenish nodules, which on 
microscopical examination are seen to 
consist of mycelium and fructifications of 
an aspergillar or penicilliar type. I saw 
the first case in Equatorial Africa, in 1902, 
in an Indian Merchant ; later Chalmers 
and I came across several cases in Ceylon. 
The simplest treatment consists, of course, 
in shaving, but if the patient objects to it, 
turpentine and diluted formalin will be 
found useful. 

TRICHOMYCOSIS AXILLARIS FLAVA, RUBRA AND 

NIGRA 

This condition has been partially known 
for many years under the term Lepothrix, 
but the various types of it were not differ- 
entiated, and nothing definite was known 
about the etiology, the affection being as- 
cribed to the most diverse germ. Eisner, 
for instance, considered it to be caused by 
a diplococcus; IP'ayne, Patterson and Peck 
inculpated various bacilli, including B. pro- 
digiosus. 

The condition is characterized by the 
presence, on the hairs of the axillary re- 
gions and occasinally the pubes; of small 
nodular formations which, from my experi- 
ence, may be yellow or red or black. I there- 
fore differentiated 3 varieties of the condi- 
tion — Trichomycosis axillaris flava, T. 
axillaris rubra, T. axillaris nigra. Accord- 
ing to my researches, T. flava is caused by 
a fungus of the genus xocardia, which I 
called N. tenuis. The red variety is caused 
the same fungus plus a red-pigment-produc- 
ing coeds, which I isolated and cultivated in 


58 


Castellani — Tropical Dermatomy coses in New Orleans and La. 


various media, and which Chalmers and 
O’Connell called Micrococcus Castellanii. 
Very rarely instead of. this coccus a red pig- 
ment producing cryptococcus is found: C. 
rubrorygosus. The black variety, T. nigra, 
is caused by the same nocardia {N. tenuis) 
plus a black-pigment-producing coccus, 
which I isolated and called N. nigrescens. 
Exceptionally instead of the coccus a black 
pigment producing cryptococcus is present : 
C. metaniger. 

It is interesting to note that natives, es- 
pecially African natives, seem to regard 
T. axillaris with disgust, and readily seek 
treatment, and Chalmers and O’Connell 
brought forward the hypothesis that the 
general custom of shaving the armpits 
among certain native tribes may have 
originated in their profound dislike of this 
complaint. 

As regards treatment, I found in Ceylon 
that 1 per cent formalin lotion applied to 
the armpits several times a day, and sul- 
phur ointment at night, answered well. In 
New Orleans Trichomycosis flava is quite 
common ; cases of Trichomycosis rubra 
occur; T. nigra is very rare. 

CONCLUSION. 

A number of tropical dermatomycoses 
occur in New Orleans and Louisiana, some 
of them being quite common. 

DISCUSSION. 

Dr. Menage: I hope you all understand all 

about the mycology of diseases of the skin. Dr. 
Castellani has made it so plain that nobody can 
leave this room without feeling that it is as sim- 
ple as it is interesting. Personally, since the ad- 
vent of Dr. Castellani here, I feel that I am suf- 
fering from a mycology complex. I thought I 
knew enough skin diseases and could recognize 
a ring worm of the body but at this moment you 
might compare my predicament to that of a kin- 
dergarten pupil given a telescope by an astron- 
omer and shown the beauties of the milky way. 
I am indeed fortunate to have only five minutes 
to discuss his paper. 

Among the diseases the general practitioner 
often sees and which sometimes taxes his patience 
beyond endurance, are what appear to be ordinary 
boils. A certain proportion of those refractory 
cases has been shown by Professor Castellani to 


be of a more serious blastomycotic type, offering 
thereby a means of getting rid of a most trouble- 
some condition to the patient. Many of the gen- 
eralized infections which we have been labeling as 
staphylococal are found to be mycotic in origin. 

This type of dermatomycosis which interests us 
most in New Orleans, and should every medical 
man in general practice is the Epidermophytosis 
Inguinale, the old time Dhobie Itch of the Span- 
ish American War. Kecently we received a com- 
munication from Washington on account of a dis- 
abling condition of the hands and feet among the 
employees of the government. An investigation 
followed this communication and a report enti- 
tled “Mycoses of the hands and feet” in which the 
writers (C. S. Butler, J. E. Houghton, and G. F. 
Cooper) report from eighteen to thirty per cent 
of the men investigated in the various services 
of the government (Marines, Navy, Hospital corps, 
etc.) had mycoses of the hands and feet. In 
New Orleans we have been seeing a great deal of 
this infection. In one of the public institutions 
which I serve as dermatologist, my monthly re- 
port of the men coming to me with skin diseases, 
show that from fifteen to twenty-five per cent 
have diseases of the hands and feet mostly of 
that type. It would be safe and fair, I believe, 
if the general practitioner (with no laboratory 
means at his command) considered seventy-five 
per cent of all skin diseases of the hands and feet 
that come to him as parasitic and treated them 
accordingly. 

The rather persistent depigmentation caused by 
Tinea flava shown by the Doctor is very inter- 
esting and curious and it occurs to me facetiously 
that if the Doctor could inoculate cases of chlo- 
asma with his Tinea flava he may cure some of 
those poor victims of the gynecologist and derma- 
tologist and claim their everlasting gratitude. 

Dr. Castellani (closing) : The remarks made 

by Professor Menage are of great interest. 

With regard to the boils, I quite agree with 
Professor Menage that in certain cases so-called 
furunculosis is not a staphylococcus infection; it is 
a cryptococcus infection. True, you find the sta- 
phylococcus always present in most of the lesions, 
but the staphylococcus is a secondary invader, not 
the true etiological agent, and it seems to me that 
this is proved by the fact that if potassium iodide 
be given in a case of staphylococcus furunculosis 
the patient gets worse, but if you give potassium 
iodide in a case of furunculosis of myetic origin, 
the eruption will disappear. 

With regard to the tinea epidermophytica of 
the toes, I am in complete agreement with Pro- 
fessor Menage. It is a condition of very great 
practical and, as he said, economical importance. 
What makes the condition very serious in certain 
cases in my opinion is not the fungus per se; it 


Reviews. 


59 


is the secondary bacterial infections. It is the 
streptococcus infection engrafted on the epider- 
mophytic condition which will give the dermatitis 
which often is found between the toes, sometimes 
with vesicles. Sometimes it will cause a lym- 
phangitis. Sometimes it will cause a condition 
which cannot be distinguished from ordinary 
erysipelas and rarely it may give true streptococ- 
cus sepsis. Moreover in patients who have 
been suffering from epidermophytosis for years, 
both between the toes and in the scrotal region, 
and in whom there is a secondary streptococcus 
infection may present attacks of fever from time 
to time, streptococcus fever, with an edamatus 
condition of the leg which at first disappears. 
Then later on the edematous condition remains 
permanent, then induration of the tissues develops 
and you have a condition which cannot be differ- 
entiated from elephantiasis. 


It seems almost impossible that a case of epider- 
mophytosis may turn into a case of elephantiasis, 
but still, indirectly, through secondary strepto- 
coccus infections, a pseudoelephantiasis condition 
develops distinguishable from true elephantiasis. 
As a matter of fact, we have a typical case here 
in New Orleans now. 

I should like to call attention to a con- 
dition of the epidermophytic origin which is not 
found in any textbook. I mean pruritus ani and 
pruritus vulvae of mycetic origin. There are a 
number of such cases which are caused by 
fungi. In these cases very often, at least in the 
beginning, yon will find no objective lesions of 
any kind, perhaps a few scratches. Later on the 
skin around the anus becomes thickened and ecze- 
matoid. It is epidermophytosis of the anal region. 
These cases never get well unless the same meas- 
ures are used as for epidermophytosis of the toes. 
My old sulphur salicylic ointment answers some- 
times very well. 


REVIEWS 


RETICULO-ENDOTHELIAL SYSTEM 
IN DISEASE.* 

RUSSELL C. PIGFORD, M. D.f 
New Orleans. 

E. B. KrumbhaarU) in an address be- 
fore the New York Academy of Medicine 
in 1923 stated, “It is convenient and desir- 
able, from a practical point of view, to 
consider all diseases of the blood, but 
especially the so-called ‘primary anemias' 
from the dynamic standpoint of the con- 
stant interplay of the blood-forming' and 
blood-destroying apparatus (which may be 
termed the hemolytopietic system) and the 
adjustment thereof spoken of as the hemo- 
lytopoietic balance.” 

“A steadily accumulating mass of evi- 
dence is forcing us to recognize that bone 
marrow, lymph nodes, spleen, liver, and 
the whole reticulo-endothelial apparatus 
must be considered as definite a mechanism 

* Second paper of the symposium on the 
Reticulo-Endothelial System, presented at a 
meeting of the Orleans Parish Medical Society, 
March 26, 1928. 

(fFrom the Department of Medicine, Tulane 
University School of Medicine.) 


for the control of cellular elements of the 
blood as the digestive or endocrine systems 
are in their respective spheres.” Thus the 
newer conception of the reticulo-endothelial 
system would not be limited to that group 
of cells that is engaged in the destructive 
processes of the blood, but must also in- 
clude a consideration of the elements im 
volved in the productive processes. 

In the normal individual, there is a con- 
stant production within physiological 
limits, of red blood cells, leukocytes, and 
platelets by the bone marrow. On the 
other hand, there is a constant destruction 
of red blood cells by the reticulo-endothelial 
cells scattered throughout the various or- 
gans of the body. In this destruction of 
red blood cells the reticulo-endothelial cells, 
in a manner that is not at present under- 
stood, play a part in the production of 
biliary pigment. Rous and Drury<2) have 
found that the amount of bilirubin present 
from day to day in the bile, yielded by 
animals with intubated common duct con- 
stitutes an immediate, if not entirely ac- 
curate index to the amount of blood de- 
struction, whether this be in part the con- 
sequences of pathological influences or 


60 


Reviews. 


merely the result of ordinary corpuscular 
wear and tear. Thus, a balance is estab- 
lished between the hemopoietic and hemo- 
lytic activities and an estimation of the 
hemolytopoietic balance at a given instant, 
Schneider has referred to as the hemo- 
poietic-hemolytic index. 

As stated above, there are physiological 
limitations of the activities of the hemoly- 
topoietic system. Any deviation from 
these limitations, whether above or below 
normal, must be considered pathologic. 
The pathogenesis is not always as evident 
as the pathologic picture. For instance, a 
leukopenia may be present in a given dis- 
ease, but the manner of production of that 
leukopenia may be not at all clear. Such a 
leukopenia may be the result of the para- 
lytic action of toxins on the hemopoietic 
cells in the bone marrow or it may result 
from an increased destruction of the cir- 
culating leukocytes by the toxins. On the 
other hand, an increase of any or all of the 
blood elements in the circulation cannot at 
a given instant be considered a result of 
the stimulaton of this or these elements by 
toxins. It is a physiological fact that rela- 
tively few of the capillaries are function- 
ing at a given instant and the blood cells 
are constantly hidden in the closed capil- 
laries. As a result of such a simple 
mechanism as exercise some of the latent 
capillaries begin to functionate and a phys- 
iological leukocytosis ensues. 

The reticulo-endothelial system is cred- 
ited with a variety of responses to 
abnormal stimulation. The cells act as 
scavengers for foreign bodies, such as an- 
thracotic pigments in the lungs. The func- 
tion of ingestion of bacteria and necrotic 
material in the body, the formation of pro- 
teolytic enzymes and the development of 
anti-bodies are attributed to this elaborate 
system. The scope of this paper will pur- 
posely not include these phases. Instead, a 
consideration of the relation of the reticu- 
lo-endothelial system to toxic reactions, 
metabolic disturbances, and blood dyscra- 
sias will be discussed. 


METHODS OF EXAMINATION. 

L BLOOD. 

Cytological: In the diseases of the 

reticulo-endothelial system the blood is the 
most valuable laboratory information we 
have at present. The color index is of ele- 
mentary importance in any study of blood 
dyscrasias. A high color index is indica- 
tive of a primary anemia, although, a long 
standing secondary anemia may produce a 
color index of 1.2 or over. In the blood 
smear the degree of anemia is roughly 
estimated by the number of anisocytes, 
poikilocytes, basophilic stippled cells, ery- 
throblasts and percentage of reticulated 
(embryonal) cells present. The estimation 
of the red cell diameters is of importance 
in differentiating between some of the 
anemias. Unfortunately, the estimation of 
the percentage of reticulated red cells has 
been a neglected field in the study of blood 
dyscrasias. The technic is very simple, re- 
quiring only a few minutes of the ex- 
aminer’s time and often giving invaluable 
information of prognostic as well as 
diagnostic importance. The leukocytic pic- 
ture is not to be neglected. A leukopenia 
is the rule in primary anemias. A normal 
leukocytosis is the rule in secondary 
anemias. However in the anemia of hem- 
orrhage a hyperleukocytosis occurs, and 
this is roughly proportionate to the severity 
of the hemorrhage. The three types of 
polymorphonuclear leukocytes, because of 
their origin in the bone marrow and their 
reaction to a quite simple staining phe- 
nomenon, are termed granulocytes. The 
peroxidase stain for the differentiation of 
these marrow cells and the non-granulo- 
cytes is at time of value in the identification 
of obscure cases of leukemia. 

Platelets: The study of the platelets is 

another somewhat neglected phase of the 
blood picture. After moderate practice in 
the study of blood smears one can usually 
estimate, though in a general way, the 
number of platelets in the blood. For 
more accurate study, however, the direct or 
indirect method of estimation is to be pre- 


Reviews 


61 


ferred. The clinical importance of these 
elements will be referred to later. 

Fragility: The resistance of the erythro- 
cytes to hypotonic salt solution is of im- 
portance in differentiating between hemo- 
lytic and non-hemolytic jaundice. The prin- 
ciple is based upon the ability of the red 
blood cells to resist dissolution when placed 
in hypotonic solutions of sodium chloride 
of graded strengths. Recently a method of 
studying the fragility of the red blood cells 
to hypotonic blood serum has been de- 
scribed with the hope that some of the 
obviously atypical conditions may be ex- 
plained on this basis. However, this study 
is as yet of doubtful value. Cholesterol 
has definite anti-hemolytic properties. In 
pernicious anemia, Gorham and Meyers 
found low cholesterol values. Since the re- 
sistance of the red blood cells to hypotonic 
salt solution is unaltered in some cases of 
pernicious anemia, it would be interesting 
to note the relationship of the cholesterol 
values of the blood to the fragility of the 
red blood cells. The writer is not cogni- 
zant of any such observation. 

Bilirubin: Ehrlich found that bilirubin 
dissolved in chloroform or alcohol and 
mixed with diazonium salts gave in a 
neutral medium a reddish, and in an acid 
medium a bluish color. This reaction he 
termed the diazo reaction. Hijmans van den 
Bergh in 1913 first applied this principle to 
the albuminous fluids, having developed a 
technic of identification of bilirubin in 
minute amounts. From his studies he 
found : first, that bilirubin is normally 
present in blood serum in a concentration 
of. one to four hundred thousand to one to 
two hundred and fifty thousand; second, 
that in cases of jaundice there was an in- 
creased intensity of the reaction compar- 
able to the degree of jaundice; third, that 
in certain types of jaundice the reaction 
was negative when applied to whole serum, 
but was positive when applied to serum 
freed from its proteins by alcoholic pre- 
cipitation. To the test with whole serum 
he gave the name, direct, and to the pro- 


tein free reaction he gave the name, 
indirect. 

This phenomenon was not popularized 
for several years, when in 1922 McNee<®> 
first recorded in English literature observa- 
tions made with the test. 

Whipple and Hooper found that bile 
pigment formation continues after remov- 
ing the liver, spleen, and intestines from 
the circulation, and that this bile pig- 
ment increased after the administration of 
a hemoglobin solution into the blood 
stream. They suggested that this biliary 
formation was due to the activity of the 
endothelial cells lining blood vessels. These 
observations together with the study of 
the van den Bergh reaction led McNee<®> 
to accept the idea of the important role of 
the reticulo-endothelial system in formulat- 
ing a new theory relative to the mechanism 
of the production of jaundice that more 
nearly conforms to the clinical and path- 
ological types of icterus. Considerable 
doubt as to the specificity of the van den 
Bergh reaction arose when Andrewes^Q) 
found that in certain cases of uremia 
showing a hypobilirubinemia the diazo re- 
action was positive. Nevertheless, Mann 
et by a spectrophotometric method 

was able to confirm the earlier observations 
on the site of bilirubin formation. The 
present view regarding the subject of 
bilirubin formation is that the reticulo-en- 
dothelial cells throughout the body play an 
important role in the formation of bili- 
rubin, that the bilirubin is carried to the 
liver as an unfinished product, and in 
passing through the liver cells is changed 
to a finished bile pigment; that in diseased 
condition there is an alteration in this 
function depending upon the type of cell 
involved in the disease process. For present 
purposes it may be said that the intensity 
of the indirect van den Bergh reaction indi- 
cates the amount of bilirubin formed by the 
reticulo-endothelial cells, and this in turn is 
an index of red blood cell destruction 
whether normal or pathologically increased. 
The van den Bergh test, because of its sim- 


62 


Reviews 


m 


plicity and its value in a large majority of 
cases, will continue to be the most valuable 
clinical procedure for differentiating hemo- 
lytic and non-hemolytic jaundice, and for 
the detection of latent jaundice in the 
hemolytic anemias. 

II. FECES AND URINE. 

The fees and urine offer limited oppor- 
tunity for observations on the clinical fea- 
tures of the reticulo-endothelial system. 
The presence or absence of bilirubin in the 
stools is of importance in the detection of 
complete obstruction to the bile passages 
and then for a limited time only. Elman 
and McMaster<ii> have shown in dogs that 
five days following complete obstruction of 
the bile ducts urobilin reappears in small 
quantities in the stools. This would sug- 
gest that in cases of complete obstruction, 
bile escapes into the intestinal tract by way 
of the blood stream. In cases of obstruc- 
tive jaundice, the kidney threshold for bili- 
rubin is low. Therefore, the study of the 
urine is of material benefit in the early 
diagnosis of this condition. However, 
McNee<*> calls attention to the fact that in 
latent hemolytic jaundice at least four van 
den Bergh units of bilirubin must be pres- 
ent in the blood before biliuria is evident. 
Thus, the van den Bergh reaction is of 
greater value than the study of the urine 
in this type of jaundice. 

REACTIONS IN INFLAMMATORY DISEASES. 

The reticulo-endothelial system responds 
in different ways to the advent of toxins in 
the human host. In a general way it may 
be said that in acute inflammatory pro- 
cesses there is a stimulation beyond physi- 
ological limits of the leukocjffic elements 
with a resulting hyperleukocytosis and an 
increase in the neutrophilic polymorphonu- 
clear cells. This increase is absolute as 
well as relative. Furthermore, it is noted 
that the neutrophilic increase is concomi- 
tant with a relative or absolute reduction 
in the eosinophilic polymorphonuclear cells 
(Simon’s septic factor). 

In contrast to the hyperleukocytic dis- 
eases there is a group of diseases in which 


the total leukocytes are strikingly reduced 
with a diminution in the granulocytic 
(neutrophilic, eosinophilic and basophilic) 
elements with a relative if not an absolute 
increase in the non-granulocytic (mononu- 
clear) cells. The most striking example of 
this leukopenic response is that of typhoid 
fever, which has been characterized as pri- 
marily a disease of the reticulo-endothelial 
system. This disease is marked by a leuko- 
penia with an increase of large mononu- 
clears. It will be recalled that the popular 
conception of the origin of the large mon- 
onuclear cells is in the endothelial linings 
of the vascular system. Histological studies 
of typhoid fever demonstrate further the 
proliferation of the large endothelial cells 
by the finding of the phagocytic cells of 
Mallory in the capillaries of the liver, 
spleen, and other organs. In dengue fever 
and kala azar, a leukopenia with an in- 
crease in the large and small mononuclears 
is seen. In influenza a leukopenia is the rule, 
while in malaria there is a tendency to a 
leukopenia with an increase of the large 
mononuclears. Measles is another disease 
in which leukopenia is seen. In Rocky 
Mountain spotted fever a hyperleukocyto- 
sis is observed with an increase of the large 
mononuclears. In this disease the mono- 
cytes are frequently the site of phagocy- 
tized red blood cells. 

In recent years a syndrome has been de- 
scribed in women about the age of forty, 
marked by an acute onset, with a localized 
angina of the mucus membranes free from 
Vincent’s organisms, running a four or five 
day septic course, and terminating fatally, 
in which the blood picture is striking. 
There is a progressive leukopenia with a 
diminution of the granulocytes for which 
the syndrome is named agranulocytic an- 
gina. The possible cause of the disappear- 
ance of the polymorphonuclear leukocytes 
from the circulating blood will not be dis- 
cussed. It will suffice to note that before 
death the total leukocyte count has been 
seen to fall as low as 250. 

Leprosy cannot be considered a disease 
of the reticulo-endothelial system. How- 


Reviews. 


63 


ever, it is interesting to note that the 
typical leper cell is an endothelial cell with- 
in which are seen large numbers of Han- 
sen’s bacili. These may be demonstrated 
in sections or in scrapings of the leprous 
lesions. 

In chronic suppurative conditions the 
formation of amyloid has been a matter of 
speculation among pathologists. Mal- 
lory <12 ) states regarding the pathogenesis 
that, “It is not a product of degeneration 
of cells of fibril or something filtered out 
of the blood stream. Instead it is a de- 
posit in tissues manufactured out of nor- 
mal constituents of the blood by cell ac- 
tivity.” He believes that the fibroblast is 
involved in the formation of amyloid. On 
the other hand, Smetana in a study of 
^he relation of the reticulo-endotheJial sys- 
tem to the formation of amyloid found: 
first, the appearance of amyloid in places 
where reticulo-endothelial cells are nor- 
mally present; second, the formation of 
amyloid early in small solitary patches 
suggesting its local formation; third, the 
Recurrence of solitary patches of amyloid 
0,pparently located within the capillaries of 
the liver ; fourth, the manifold relations be- 
tween reticulo-endothelial cells marked out 
by phagocytized ink granules and amyloid ; 
fifth, the impossibility of demonstrating 
reticulo-endothelial cells in areas forming 
amyloid; sixth, the delayed appearance of 
amyloid in animals after blockage of the 
reticulo-endothelial cells by repeated injec- 
tion of India ink. These observations 
strongly suggest a relationship of the re- 
ticul<}-endothelial system to the formation 
of amyloid. 

The leukocytic phase of malaria has pre- 
viously been referred to. The fact that a 
large spleen is always associated with 
malaria has been a subject of speculation 
for a possible disturbance of reticulo-endo- 
thelial physiology. The enlargement is due, 
in part, to the great accumulation of endo- 
thelial leukocytes filled with red blood cells 
and blood pigment. The hemolytopoietic 
balance is disturbed as a result of in- 


creased red cell destruction manifested 
clinically by an anemia of the secondary 
type, a hemolytic jaundice and a urobili- 
nuria. As convincing evidence of the 
hemolytic type of jaundice the indirect van 
den Bergh is positive. Occasionally, how- 
ever, in chronic malaria Hughes<^^> has 
noted that the direct van den Bergh is 
biphasic, which would indicate that in ad- 
dition to a hemolytic jaundice, there is 
present a toxic process involving the liver 
cells. 

METABOLIC DISEASES. 

In disturbances of fat metabolism, cs) oe) 
the reticulo-endothelial system shows defin- 
ite evidence of activity. In the lipemia of 
diabetes mellitus the spleen is swollen and 
tender, and on section, is found to be 
clogged with large numbers of endothelial 
cells containing globules of fat. 

Gaucher’s disease is now classed by 
many authorities as a familial metabolic 
disorder of the lipoid elements. In the en- 
dothelial cells of the liver and the large 
spleen in cases of Gaucher’s disease are 
found lipoid deposits demonstrable by mi- 
crochemical methods. The persistent leu- 
kopemia is another feature of this type of 
splenomegaly. 

BLOOD DYSCRASIAS. 

Pernicious Anemia. Pernicious anemia 
is a disease essentially of late adult life 
that follows a variable course, subject to 
remissions, practically always fatal, and 
characterized by a lemon yellow skin, en- 
larged spleen, a megalocytic anemia of a 
primary type, and a leukopenia. In this 
disease there is a marked fluctuation in the 
blood picture from time to time, and this 
fluctuation is roughly proportional to the 
subjective phenomena. This is the disease 
par excellence for following the fluctuations 
in the hemol3d;opoietic balance. During the 
stage of relapse there is observed a pro- 
gressive anemia with very slight evidence 
of regeneration as indicated by the paucity 
of nucleated red cells and reticulocytes in 
the peripheral blood. Simultaneously with 
the progressive anemia the fragility of the 


64 


Reviews. 


red cells is increased and there is increased 
bile pigment (indirect van den Bergh) in 
the blood stream, an increase of stercobilin 
and a urobilinuria. During the period of 
regeneration, that is, when the hemopoietic 
phase is active and the hemolytic phe- 
nomena are relatively quiescent, large num- 
bers of erythroblasts and reticulated cells 
appear in the blood, the resistance of the 
red cells increases, and the van den Bergh 
reaction approaches normal. In fact, all 
the features of the disease may disappear 
and the patient enjoy apparently perfect 
health for a variable period of time. 

Banti’s Disease. The large spleen of 
Banti’s disease with the increased number 
of macrophages and endothelial cells to- 
gether with increased amount of blood 
pigment are indicative of a hemolytic pro- 
cess in this disease. The anemia, how- 
ever, differs from that of pernicious 
anemia in that it tends to a chlorotic type 
with a tendency to a microcytosis. Except 
after severe hemorrhages when there is 
marked stimulation of the bone marrow, 
the hemopoietic tissues show relatively 
little activity as evidenced by the presence 
in the circulating blood of few erythro- 
blasts and reticulocytes. There is no 
striking alteration in the resistance of the 
red blood cells in this disease. The hemo- 
lytic nature of splenic anemia is mani- 
fested by increased bile pigment in the 
blood (indirect van den Bergh) and an in- 
crease of urobilin in the feces and at times 
a urobilinuria. It might be said in this 
connection that after the periportal cirrho- 
sis of the liver has progressed to the stage 
of liver cell damage, the direct van den 
Bergh may become positive. A leukopenia 
is the rule, although hyperleucocytosis may 
be observed after hemorrhage. Rosen- 
thal<i^> divides Banti’s disease into two 
groups according to the platelet count. In 
one group he finds a thrombocytopenia and 
in another a thrombocythemia. He be- 
lieves splenectomy is beneficial in the first 
group, while in those cases showing an in- 
creased platelet count, no improvement is 
noted. 


Hemolytic Jaundice. Hemolytic icterus 
is manifested by jaundice, splenomegaly, a 
severe anemia of the hemolytic type and in- 
creased fragility of the red blood cells. At 
certain periods of the disease there is 
marked similarity to pernicious anemia. In 
the blood smear of hemolytic jaundice, 
however, the extreme activity of the bone 
marrow as reflected in the finding of enor- 
mous numbers of erythroblasts and a retic- 
ulocytosis of twenty times normal is not 
seen in any other disease. Furthermore, 
there is a tendency to a microcytosis in 
hemolytic jaundice in contradistinction to 
the megalocytosis of pernicious anemia. 
The engorged spleen with evidence of in- 
creased activity of the reticulo-endothelial 
cells, that is, the increased number of these 
cells wjth large quantities of blood pig- 
ment incorporated within the cells suggests 
a localization within the spleen of patholo- 
gic reticulo-endothelial physiology. As 
confirmatory evidence of this localization 
process, the relief of symptoms after splen- 
ectomy needs only to be mentioned. In 
pernicious anemia the evidence of blood 
cell destruction is not limited to the spleen, 
but is observed in the reticulo-endothelial 
cells of other organs (Kuppfer cells of the 
liver). This is offered as an explanation 
of the failure of splenectomy to relieve 
the symptoms in pernicious anemia. 

The resistance of the red blood cells to 
a hypotonic salt solution is greatly dimin- 
ished in hemolytic jaundice. The cause of 
this increased fragility is not at all under- 
stood. Since the spleen seems to be the 
site of the lesion, it has been suggested 
that the disturbance of resistance results 
from toxic bodies elaborated by the spleen. 
One would naturally conclude that removal 
of the spleen would result in a return to 
normal of the resistance of the erythro- 
cytes. Contrary to expectation, this occurs 
in only about fifty per cent of the cases. 
Failure to return to normal in all of the 
cases may be a result of a partial accept- 
ance of splenic function or a spread of the 
pathological lesion to other parts of the 
reticulo-endothelial system. 


Reviews 


65 


Sickle Cell Anemia. A condition closely 
simulating hemolytic jaundice, but differ- 
ing from it in a few details is sickle cell 
anemia. The chief points of similarity are : 
the apparent familial tendency, the extreme 
chronicity, the tendency to exacerbation of 
symptoms with the appearance of a hemo- 
lytic jaundice, an increased bilirubin con- 
tent of the stools with the occurrence of a 
urobilinuria, the presence during the ex- 
acerbation of large numbers of erythro- 
blasts and reticulocytes, and the positive 
indirect van den Bergh. The differential 
features are: the occurrence of sickle cell 
anemia in the negro race (only one excep- 
tion having been recorded) The spleen 
of sickle cell anemia is diminished in size. 
In this connection the writer recalls an 
autopsy at Charity Hospital, New Orleans, 
in which extreme difficulty was experi- 
enced by the pathologist in identifying 
splenic tissue. The leukocytes in sickle cell 
anemia are markedly increased as high a 
count as 64,000<^®> having been reported. 
The most striking difference is the occur- 
rence in the blood stream of patients with 
sickle cell anemia of peculiar elongated 
banana shaped red blood cells. It was the 
finding of these fusiform cells that sug- 
gested the term sickle cell anemia to 
Herrick. While the fragility of the red 
cells is constantly increased in hemolytic 
jaundice, reports on this feature are at 
variance in sickle cell anemia. In the lat- 
ter, the hemolytic span varies from normal 
to a reduced resistance within normal 
range, to a reduced resistance with an in- 
creased range. Generally speaking, it may 
be said that there is a tendency to in- 
creased fragility of the red blood cells in 
sickle cell anemia. 

Splenomegalic Polycythemia (Polycythe- 
mia vera). In contrast to the hemolytic 
diseases, polycythemia vera is a condition 
primarily of hyperplasia of the bone mar- 
row involving the erythroblastic tissues, re- 
sulting in an abnormal production of ery- 
throcytes, both qualitative and quantita- 
tive. The spleen is markedly enlarged in 
this disease. The enlargement is consid- 


ered to be a compensatory affair, the 
splenomegaly resulting from an effort on 
the part of the spleen to destroy the in- 
creased number of red blood cells. The 
only changes noted in the splenic structure 
are a general enlargement, with marked 
engorgement of the blood vessels. The 
total erythrocytes are markedly increased, 
at times more than twice normal. The 
hemoglobin is increased but not in propor- 
tion to the red blood cells, resulting in a 
low color index. That there is a stimula- 
tion of the hemolytopoietic system beyond 
physiological limits is further evidenced by 
the finding of all types of red blood cell 
changes in the blood smear. Embryonal 
forms such as nucleated red cells and retic- 
ulocytes are a constant finding during the 
exacerbations. Polychromatophilia is noted, 
but the striking staining characteristic of 
the red blood cells is an achromia. A 
hyperleukocytosis with the appearance in 
the blood stream of immature leukocytes 
accompanies the hypererythrocytosis. In 
fact leukemic pictures have been de- 
scribed, 

The platelets, as a rule, are unaltered, 
but occasionally the disease process may 
also involve this phase of the bone marrow, 
resulting in an increased platelet count. 
The fragility of the red cells varies con- 
siderably in polycythemia. As a rule, how- 
ever, there is a tendency to lengthening of 
the resistance range. It has been sug- 
gested by Minot and Buckman^^o) that this 
fluctuation is due to the presence of cells 
of greater age variety than normal. 

Increased hemolytic activity is evidenced 
by the large engorged spleen with an in- 
creased quantity of bilirubin in the blood 
and an increased stercobilin. For the 
reason that there is an abnormal disturb- 
ance of the hemolytopoietic balance, poly- 
cythemia vera is classed as a definite dis- 
ease of the reticulo-endothelial system with 
the primary pathology localized in the 
hemopoietic structures. 

Idiopathic Thrombocytopenic Purpura. 
The diseases previously discussed under 


66 


Reviews 


the title of blood dyscrasias are those of 
pathological changes in the reticulo-endo- 
thelial system affecting primarily the ery- 
throcytic element. While in essential 
thrombocytopenia the erythrocytic and at 
times the leukocytic elements may be in- 
volved, nevertheless, this disease is essen- 
tially one of disturbed platelet physiology. 
In all cases there is a marked diminution 
in the number of circulating platelets, and 
in about fifty per cent of the cases palpable 
enlargement of the spleen is noted. These 
facts immediately suggest a relationship of 
the spleen to platelets in the pathogenesis 
of this disease. To confirm such a rela- 
tionship one need only to refer to the pro- 
lific literature, reporting most favorable 
symptomatic results following splenectomy. 
What role the spleen plays in the disease 
is as yet a matter of speculation. See- 
liger<2i) in post-mortem examinations of 
six cases found evidence of degeneration 
of the megakaryocytes. He suggested that 
the pathology might be a localized process 
in the bone marrow. On the other hand, 
clinical evidence in splenectomized cases 
suggests very strongly the spleen as the 
primary site of perverted physiology. If 
the spleen is the site of increased platelet 
destruction, one would expect to find a re- 
turn of the platelets to normal after 
splenectomy. This does actually take place 
in many cases, but in some<22) it is only 
temporary in spite of a disappearance of 
all symptoms of the disease. From this 
observation it may be suggested that the 
clinical picture is not entirely a result of 
a thrombocytopenia, but is in part due to 
other factors not yet understood. 

The fragility of the red cells and the 
production of bilirubin are unaltered ex- 
cept in complicated cases. 

Leukemias, Polycythemia vera has been 
referred to as a disease of the reticulo-endo- 
thelial system in which there is a hyper- 
plasia of the erythroblastic tissues. Leuka- 
mias may be looked upon as hyperplastic 
diseases of the leukoblastic tissues in which 
there is thrown into the circulation large 
numbers of immature leukocytes. In mye- 


logenous leukemia the lesion is localized in 
the bone marrow, while in lymphatic leu- 
kemia it is localized in the lymph nodes. 
Mallory believes the leukemias to be 
tumors of the leukoblastic tissue. In both 
myelogenous and lymphatic leukemia, 
splenomegaly is a part of the picture. 
The spleen at times reaches enormous pro- 
portion in the myelogenous type. No 
satisfactory explanation for the splenome- 
galy has been advanced. The fact that 
few cases are benefitted by splenectomy 
would exclude the probability that the 
spleen plays any but a passive part in the 
disease. In myelogenous leukemia the 
frequent finding of immature red cells in 
the blood smear without a marked anemia 
suggests an involvement of the erythroblas- 
tic as well as the leukoblastic tissues. 

The chronic forms of myelogenous and 
lymphatic leukemia do not as a rule offer 
any difficulty in differentiation. However, 
there is a form of acute leukemia in which 
the origin of the cell cannot be determined 
by ordinary staining methods. The cells 
seen in this type of leukemia are large, em- 
bryonal, mononucleated cells. Ordway and 
Gorham < 23 ) call attention to the fact that 
the myeloblasts and myelocytes liberate 
oxydizing ferments demonstrable by 
means of the peroxidase stain. By ap- 
plying this stain to the smears it has been 
found that the leukocytes of many of the 
so-called acute lymphatic leukemias, be- 
cause of the presence in the cells of the ox- 
idizing substance, are granulocytes, there- 
fore generically myeloid cells. This simple 
staining phenomenon has thus been of con- 
siderable benefit in ante-mortem classifi- 
cation of some of the obscure cases, usually 
referred to as acute lymphatic leukema. 

SUMMARY. 

A consideration of the role of the retie- 
ulo-endothelial system in disease must be 
considered as a pathologic alteration of the 
hemolytopoietic balance. 

The various laboratory methods of de- 
termining the hemolytopoietic index are 
briefly discussed. The indirect van den 


Reviews 


67 


Bergh reaction is a valuable addition to 
laboratory procedures in the study of the 
diseases of the reticulo-endothelial system. 

In acute inflammatory diseases a dis- 
turbed reticulo-endothelial physiology is 
manifested chiefly by an alteration in the 
normal leukocytic element. 

In chronic suppurative diseases the 
reticulo-endothelial system seems to play a 
part in the formation ofamyloid. 

The erythrolyto poietic balance is pri- 
marily involved in such diseases of the re- 
ticulo-endothelial system as pernicious 
anemia, Banti’s disease, hemolytic jaundice, 
sickle cell anemia and polycythemia vera. 

The thrombolytopoietic balance is dis- 
turbed in idiopathic purpura hemorrhagica. 

The leukemias are placed in the category 
of reticulo-endothelial diseases because of 
the pathological alteration of the leukolyto- 
poietic balance. 

BIBLIOGRAPHY. 

1. Krumbhaar, E. B. : Hemolytopoietic system in the 

primary anemias with a further note on the value of splen- 
ectomy. Am. Jour. .Med Sc., 166 :329, 1923. 

2. Rous, Peyton and Drury, D. R. : Jaundice as an 

expression of the physiological wastage of corpuscles. 
Jour. Exp. Med., 41:601, 1925. 

3. Schneider quoted by Krumbhaar, See 1. 

4. Gorham, Frank O. and Myers, Victor C. : Remarks 

on the cholesterol content of human blood. Arch. Int. 
Med., 20:599, 1917. 

5. McNee, J. W. : The use of the van den Bergh test 

in the differentiation of obstructive from other types of of 
jaundice. Brit. Med. Jour., 1:716, 1922. 

6. Whipple, G. H. and Hooper, C. W. : Hematogenous 

and obstructive jaundice. Jour. Exp. Med., 17 :593, 1913. 

7. Whipple, G. H. and Hooper, C. W.: A rapid change 

of hemoglobin to bile pigment in the circulation outside 
the liver. Jour. Exp. Med., 17:610, 1913. 

8. McNee, J. W. : Discussion of Jaundice. Brit. Med. 

Jour., 2:495, 1924. 

9. Andrewes, quoted by L. F. Hewitt: Diazo reaction 

in uremic sera. Biochem. Jour., 19:171, 1925. 

10. Mann, Sheard, Bollman and Blades: The site of 

formation of bilirubin. Am. Jour. Phys., 74:497, 1925. 

11. Elman, Robert and McMaster, Philip D. : Urobilin 

physiology and pathology. Jour. Exp. Med., 41 :503, 1925. 

12. Mallory, F. B.: Principles of pathologic histology. 

Page 103, W. B. Saunders Co., Philadelphia, 1914. 

13. Smetana, H. (Peking) : The relation of the reticu- 

lo-endothelial system to the formation of amyloid. Jour. 
Exp. Med., 45:619, 1927. 

14. Hughes. T. A. : The origin of urobilin in persons 

who have suffered from chronic malaria. Indian Jour. Med. 
Research, 14:157, 1926. 


15. Krumbhaar, E. B. : The so-called reticulo-endothe 

lial system. International Clinics, 2:280, 1925. 

16. Smith, Margaret G. : Hyperplasia of lipoid holding 

cells in diabetes with lipemia. Bull. J. Hopkins Hosp., 
36:203, 1925. 

17. Rosenthal, N. : Clinical and hematological studies 

on Anti’s disease. Jour. A. M. A., 84:1887, 1925. 

18. Smith, J. H., quoting Archibald: Sickle cell ane- 

mia. Med. Clin. N. Amer. (Mar.), p. 1178, 1928. 

19. Herrick, J. B.: Peculiar elongated and sickle shaped 
red blood corpuscles in a case of severe anemia. Arch. 
Int. Med., 6:517, 1910. 

20. Minot, George R., and Buckman, Thomas E. : Ery- 
thremia. Amer. Jour. Med. Sc., 166:469, 1923. 

21. Seeliger, S. : Organic changes and their signifi- 
cance in the pathogenesis of essential thrombopenia and 
aleukemia. Klin. Wochen, 3:731, 1924. 

22. Brill, N. E., and Rosenthal, N. : The curative 

treatment by splenectomy of chronic thrombocytopenic pur- 
pura hemorrhagica. Amer. Jour. Med. Sc., 166:503. 1923. 

23. Ordway, Thomas, and Gorham, L. Whittington: 
Cecil’s Text-book of Medicine, p. 935. W. B. Saunders & 
Company, Philadelphia, 1927. 


Health Work and the Mississippi Flood. — The work of 
emergency relief and reconstruction in the lower Mississippi 
basin, which was devastated by floods in the spring and 
summer of 1927, affords a stirring example of what private 
organizations and government services can accomplish when 
they combine to carry out a unified plan of campaign. 
Twenty thousand square miles had been inundated, 250 
persons drowned and 700,000 driven from their homes; the 
crops on two millon acres had been lost. The damage to 
property was put at more than two hundred million dollars. 
The American National Red Cross, a voluntary associa- 
tion in spirit and methods although semi-official in its close 
relations wtih the Federal Government, took the lead in 
relief measures. Trained workers were instantly mobilized 
and supplies sent forward ; at the same time an appeal was 
made to the public for funds. The President appointed the 
Secretary of Commerce as a special representative in the 
area. The organizing genius of this official brought into 
one great common effort the Red Cross, the Army and 
Navy, the United States Public Health Service and other 
federal units. State authorities, local officials, the railways, 
the Federal Farm Loan Board, scores of private societies, 
and a vast band of voluntary workers. At a meeting in 
New Orleans in June, 1927, a program was worked out by 
which the United States Public Health Service, the health 
departments of seven States which had been affected by 
the flood, and local county governments were to co-operate 
in establishing county health organizations in 100 counties 
of the flooded area. The Rockefeller Foundation agreed to 
contribute towards this plan, which called for a total of 
$1,250,000 over a period of a year and a half. By the end 
of 1927 eighty-five counties had arranged for such organiza- 
tions and the Foundation had given $200,000. A pledge to 
continue the co-operation through 1928 has been made. — 
Vincent, George E. : The Rockefeller Foundation, a Review 
for 1927, New York, 1928, p. 14. 


68 


Editorials. 


NEW ORLEANS 


Medical and Surgical Journal 

Established 

Published by the Louisiana State Medical So- 
ciety under the jurisdiction of the following named 
Journal Committee: 

L. J. Menville, Ex-Officio 
For three years, H. W. Kostmayer, M. D., 
Secretary, S. M. Blackshear, M. D. 

For two years, H. B. Gessner, M. D., Chairman 
For one year, Paul J. Gelpi, M. D., Lucien 
Ledoux, M. D. 

EDITORIAL STAFF 

John H. Musser, M. D Editor 

H. Theodore Simon, M. D Associate Editor 

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Williard R. Wirth, M. D Associate Editor 

Frank L. Loria, M. D Associate Editor 


COLLABORATORS— COUNCILLORS 


For Louisiana 
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C. C. DeGravelles, M. D. 
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A. G. Maylie, M. D. 

D. C. lies, M. D. 

G. M. C. Stafford, M. D. 


For Mississippi 
J. W. Lucas, M. D. 

J. S. Donaldson, M. D. 
M. W. Robertson, M.D. 
T. W. Holmes, M. D. 

D. W. Jones, M. D. 

W. G. Gill, M. D. 

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for statements made by any contributor. 

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1551 Canal St., New Orleans, La. 


THE SEMI-CENTENNARY 
CELEBRATION. 

In this number of the Journal there is 
published the complete account of the 
Fiftieth Anniversary celebration of the Or- 
leans Parish Medical Society together with 
the addresses that were delivered at this 
meeting. The Society was indeed fortu- 
nate to have such a splendid list of speak- 
ers and to have men so well qualified to 
speak from personal observation and expe- 
rience. The first address, a review of 
medical education in Louisiana by the dean 
of the medical profession of New Orleans, 
that grand old man, Dr. E. S. Lewis, is in- 
deed authoritative, as the speaker had 


taught for many, many years in New Or- 
leans, in fact from comparative youth up 
until a few years ago when he resigned on 
account of age. The early history of the 
Orleans Parish Medical Society is a splen- 
did resume in brief of the events which led 
to the founding of the Society and its sub- 
sequent history in its early days. Fully 
competent to speak as a student of medical 
chronicles and a notable medical historian, 
Dr. A. E. Fossier presents a splendid his- 
torical sketch of the organization. The 
charm and the appeal of Dr. G. Farrar Pat- 
tons extemporaneous address can not be 
appreciated as well in the cold printed 
words, as it was by those who had the 
good fortune to hear his delightful presen- 
tation. The oration of the Honorable T. 
Semmes Walmsley, with vigor and with 
power, calls attention to some of the delin- 
quencies of the medical profession, espec- 
ially in their relationship to public legisla- 
tion. His statements should be accentu- 
ated fully and emphasized forcibly. If the 
medical profession hopes to maintain the 
present high standards of medical prac- 
tice, it can not do it by the efforts of a mere 
handful of men. It requires the organized, 
cohesive action of the entire body medical 
to get behind the existing legislative acts, 
to work for them, to watch that they are 
ever borne aloft, and what is of even more 
importance to see that they are not stulti- 
fied by the activities of cultists and faddist. 


MULTIPLICITY OF MEDICAL 
MEETINGS. 

At the recent meeting of the House of 
Delegates of the American Medical Asso- 
ciation in Minneapolis, numerous resolu- 
tions and recommendations were proposed, 
most of which were voted down as con- 
trary to the purposes and aims of the Asso- 
ciation. There was, however, one resolu- 
tion which it seems worth while to com- 
ment upon more than briefly. This reso- 
lution referred to the very large number of 
medical meetings which are held in the 
larger communities where there are con- 
siderable number of hospitals. As a result 


Editoimls. 


69 


of the agitation in the American College of 
Surgeons these hospitals have felt it neces- 
sary to hold at regular intervals staff meet- 
ings at which scientific programs were pre- 
sented. It was felt by the House of Dele- 
gates of the Association that these staff 
meetings did much to detract from the 
meetings of organized medicine. They are 
held at frequent intervals ; they are not open 
to the general medical public and they are 
essentially local. It is felt that members 
of the staffs of the hospitals, spending con- 
siderable number of evenings a month at 
these meetings, neglect to attend the regu- 
lar meetings of organized medicine. By 
their absence they take away an important 
element of the Society, they weaken scien- 
tific programs, and they are not able to 
enter whole-heartedly into the duties which 
an active organization requires of its mem- 
bers. In addition to the factor of requir- 
ing too much time, it was felt by the dele- 
gates that it was not consistent with the 
purposes of the American Medical Associa- 
tion for its members to be obliged at the 
virtual command of an organization which 
comes in contact with only a small fraction 
of the medical profession to be subservient 
to the orders issued by this particular or- 
ganization. Lastly, it was felt that the 
American Medical Association itself should 
make a thorough study of hospitals and pre- 
pare a list of acceptable hospitals. 


PERNICIOUS ANEMIA. 

For many years pernicious anemia has 
been considered entirely a hemolytic dis- 
ease, a disease in which excessive hemolysis 
of the red cells is held responsible for the 
severe anemia. In view of the epoch-mak- 
ing discovery of the effect of liver, and to a 
lesser extent of kidney, upon the anemia, 
it will be necessary to discard our older 
views as to the genesis of this type of 
anemia. It is very difficult indeed to con- 
ceive of hemolysis itself being effected by a 
food factor. The mere taking by mouth 
of a particular type of protein should cer- 
tainly have no effect on a disease which 


might be caused by microorganisms or 
hypothetical toxins in the body which de- 
stroy the red cells. It would seem more 
equitable then to adjudge pernicious anemia 
as a disease somewhat similar to or related 
to the so-called deficiency diseases. Liver 
supplies the element which the individual 
suffering from pernicius anemia needs. 
This particular food factor definitely brings 
about the maturation or ripening of the red 
sells so that they can come out into the 
general circulation. If they become capa- 
ble of doing this or it is rendered possible 
for them to get in the blood stream the 
anemia disappears and the classical picture 
of this pernicious type of blood dyscrasia is 
gone. One of the important evidences that 
pernicious anemia was hemolytic in type re- 
sides in the fact that there is a very large 
deposition of iron in some of the internal 
organs. This could well be present in a 
type of anemia in which the red cells do not 
fully ripen, explainable by the fact that 
these cells are unable to utilize the iron in 
the body which is deposited in the tissues 
rather than in the circulating red cells. The 
clasmatocytic destruction of red cells in the 
bone marrow, shown by Peabody and Doan 
to be present in pernicious anemia simply 
is a result of the feeding of these phago- 
cytes upon the rich pabulum of red cells 
which were packed in the marrow as in 
a tight box unable to reach the systemic 
circulation. 

It is a remarkable fact that many of our 
ideas and conceptions of disease which we 
have thought in the past to be upon indis- 
putable foundations, have changed materi- 
ally as the result of one or two pieces of 
experimental and clinical observation 
which has escaped investigators in the past. 
Pernicious anemia seems to be in this cate- 
gory. A new concept of the genesis of this 
disease will be necessary in the future as 
the result of the effect of specific treatment 
upon the course of the malady. 


70 


EditomUs. 


RADIOLOGICAL FRAUDS AND IM- 
PROPER PRACTICES. 

The roentgenologist, like the surgeon, has 
had to contend most strenuously against 
iniquitous unethical forms of fee-splitting. 
Masquerading under various disguises, this 
evil is apparently becoming quite prevalent 
in the world of the radiologists. The diffi- 
culty of combating this deceitful practice 
lies in the clever camouflage that roentgen- 
ologic laboratories are able to employ, es- 
pecially those not under the immediate 
control of a physician. The Radiological So- 
ciety of North America, at its recent meet- 


ing in New Orleans, called attention most 
forcibly to these practices, which it branded 
improper, unethical and dishonest. In a 
series of resolutions, the organization op- 
posed vigorously such practices, and stated 
that any radiologist engaged in improper 
and unethical practice should be disbarred 
from membership in the organization. Of 
particular moment and force was the 
seventh resolution, which labeled and cata- 
logued a roentgen-ray laboratory as un- 
ethical if diagnostic reports, based upon 
film-readings of technicians without a medi- 
cal degree, emanate from such a laboratory. 


HOSPITAL STAFF TRANSACTIONS 


CHARITY HOSPITAL MEETING. 
MEDICAL SECTION. 

TTie regular monthly meeting of the medical sec- 
tion of the Charity Hospital Staff was held June 
19, 1928, at 8 P. M., Dr. Bethea presiding. 

Dr. Otis first presented a young female patient 
upon which the diagnosis of functional vomiting, 
cystitis, and herpes labialis had been made. The 
outstanding features of the case were the recurrent 
attacks of vomiting, and a certain peculiar swelling 
of the legs associated with a stomatitis. These 
complaints had resisted many forms of therapy. 
One urine analysis showed the presence of 4% per 
cent albumin and many pus cells. 

Dr. Lyons discussed this case with reference to 
the marked albuminuria which he thought to be too 
pronounced to be accounted for by the pyuria. He 
suggested the possibility of the case being an angio- 
neurotic edema associated with a nephrosis. Dr. 
Bethea discussed the case with regard to food 
albergy, mentioning milk especially. 

The second case shown by Dr. Otis was an obese 
young female who had been unable to walk upon her 
admission to the hospital. Her neurological exam- 
ination had been entirely negative. She is now 
ha\dng no difficulty in walking, the diagnosis of 
pyschoneurosis being made. 

Two very interesting cases were shown by Dr. 
Giles. The first, a white female 58 years of age, 
was a case of tumor of the posterior lobe of the 
pituitary gland. The diagnosis was borne out 
clearly by the lateral views of the skull demonstrat- 
ed by Dr. Granger. The woman showed the en- 
larged massive facial features and the very typical 
“spade” hands. The therapy of the case had con- 
sisted of roentgen-ray applications to the gland 
with an apparent partial relief of her severe head- 
aches, a lowering of the basal metabolism from + 42 
to -f 11, and an alleged improvement in her facial 
characteristics. Questions asked elicited the facts 


that her blood pressure was normal and there were 
no visual disturbances. 

The second case shown by Dr. Giles was a male 
diabetic being treated with synthalin. The progress 
of the case was summarized, and it was shown that 
the diabetes was apparently under control on a 
full diet without insulin, but with synthalin. This 
patient had had hypoglycemic reactions following 
the use of too large doses of the drug through an 
error. The tendency of the drug to produce a 
hepatitis was discussed, the case under discussion 
having a weak diazo reaction indicating some he- 
patic impairment. 

Drs. Lyons and Bethea discussed the case briefly. 
This was the closing meeting until October. 

WILLARD R. WIRTH, M. D. 

THE SONIAT MERCY HOSPITAL. 

Drs. Mullens, Waters and Rigall were appointed 
Junior Internes for the year beginning July, 
1928. 

Dr. Hauser presented several cold specimens 
with their history and pathology: 

(1) A case of hemolytic staphylococcus 
aureus. Admission diagnosis was mastoiditis. 
Operated. Blood culture showed the hemolytic 
staphylococcus. The non-hemolytic is common 
and recovery is the rule. There is a one hundred 
per cent mortality with the hemolytic however. 

(2) A case of septic thrombo-phlebitis ex- 
tending as far as the inferior vena cava with no 
edema of the extremities. 

(3) Several specimens of pathological ap- 
pendicies. (a) Carcinoma of the appendix, (b) 
Multiple bird shot in the appendix lumen, and 
(c) Carcinoma of the tissues immediately adjacent 
to the ilio-cecal valve. 

MAURICE CAMPAGNA, M. D., Sec’y- 


TRANSACTIONS OF ORLEANS PARISH MEDICAL SOCIETY 


During the past month the Society has held its 
regular Board Meeting, one Joint Clinical Meet- 
ing with the Charity Hospital Staff and one Scien- 
tific Meeting. 

At the Clinical Meeting cases were presented 
by the following: Drs. P. A. Mcllhenny, E. D. 
Fenner, Urban Maes, Jerome E. Landry, J. H. 
Smith, Jr., Alton Ochsner, and A. Henriques. 


At the Scientific Meeting held June 25th, the 
following papers were read and discussed: 
Appendicitis in Children. 

By Dr. Chas. J. Bloom. 

Discussed by Drs. Urban Maes, E. Denegre 
Martin, and John F. Dicks. 

The Use of Lipiodol as an aid to diagnosis in 
Sinus Conditions. Preliminary Report. 

By Dr. A. I. Weil and Dr. W. F. Henderson. 

Discussed by Dr. H. L. Kearney and Dr. L. 

J. Menville. 


During the past month the Society extended an 
invitation to the American Psychiatric Associa- 
tion, the American Association for the Study of 
Epilepsy, and the National Association for the 
Study of Feeblemindedness, to hold their 1929 
convention in New Orleans. This invitation was 
to be extended through Dr. J. N. Thomas, Super- 
intendent of the Central Louisiana State Hos- 
pital, 


Dr. H. C. Dilworth was elected to Interne Mem- 
bership and Dr. Frank J. Beyt and Dr. J. Kelly 
Stone were elected to Active Membership. 


The Library of the Society has received a com- 
plete line of publications in the form of reprints 
and pamphlets of the National Committee for 
Mental Hygiene. Many of these pamphlets are 
for the laity, but to medical men they will prove 
of interest in detailing many features of mental 
hygiene in childhood particularly, which advice 
is often sought from him by parents. 


TREASURER’S REPORT. 

Actual Book Balance, 4-30-28 $1,121.15 

Receipts during May..„. 1,381.58 

$2,502.73 

Expenditures $1,010.11 


$1,492.62 

Outstanding checks 129.99 


LIBRARIAN’S REPORT. 

Thirty-two books have been added to the Library 
during April. Of these 6 were received by gift, 
10 by exchange, 4 by binding and 18 from the 
New Orleans Medical and Surgical Journal. Note 
is made of new titles of recent date in the list 
herewith appended. 

Three reference lists have been prepared and 
added to the files on subjects as follows: 

Articles by Calve 1900-20. 

Euphyllin. 

Sedimentation test. 

The cataloging of our pamphlet collection has 
continued as fast as the daily reference calls 
would permit 110 being added to our files during 
May. 

The new shelving has been received and con- 
structed, and the subsequent shift into this extra 
space is in progress. 

NEW BOOKS. 

Frankel — State aided hospitals in Pennsylvania. 
1925. 

Emerson — Physical diagnosis. 1928. 

Thomas — Asthma. 1928. 

Grover — High frequency practice. 1928. 

Miller — 'Safeguarded thyroidectomy. 1928. 

Shastid Outline history of opthalmology. 

1927. 

Woldenberg — ^Prevention of preventable ortho- 
pedic defects. 1927. 

de Takats — Local anesthesia. 1928. 

Amer. Assn, of Med. Certified Milk Conferences. 

1927. Milk Commissions. 

Balker — Young man and medicine. 1928. 

Lynch — Communicable and other diseases in 
the World War. 1928. 

Amer. Surg. Assn. — Transactions. 1927. 

May — Diseases of the eye. 1927. 

Nord — Etude sur Tinfluence de quelques de- 
rives de I’albumine sur la regulation du sucre du 
sang. 1926. 

Young — Treatment of infections and infectious 
diseases with mercurochrome-220 soluble. 1925. 

Stanford University — Bulletin vol. 8. 1924-27. 

Rose — Physical diagnosis. 1927. 

DeLee — Principles and practice of obstetrics. 

1928. 

Hare — Use of symptoms in diagnosis. 1928. 

Crossen — Gynecology for nurses. 1927. 

Cho^pra — ^Anthelnrinties and their "use. 1928. 

Schellberg — Mechanics and chemistry of the 
human body. 1928. 

Sante — Lobar pneumonia. 1928. 

Dakin — Elements of general zoology. 1927. 

Jahreskiirse fur arzthiche Fortbildung, v. 1, 6- 
14. 1910, 1915-23. 

H. THEODORE SIMON, M. D., 

Secretary. 


Bank balance 


$1,622.61 


72 


Orleans Parish Medical Society 


CELEBRATION OF THE GOLDEN ANNIVER- 
SARY OF THE ORLEANS PARISH 
MEDICAL SOCIETY. 

Monday, May 7, 1928- 
Hutchinson Memorial. 

Dr. J. B. Guthrie: Ladies and gentlmen, it 

is a great pleasure to welcome you here in the 
name of the Orleans Parish Medical Society 
on our Golden Anniversary. We have lived a 
long time. It seems a long time to some of 
us — but it is a wonderful privilege to have 
been with the Orleans Parish Society for even 
one-half of these years that we are commemor- 
ating. However, it is not my function to re- 
count the history of the Orleans Parish Medical 
Society. That will be done by far more capable 
men than I. We are here simply to commemorate 
this event and to co-ordinate our work with the 
public, and to bring up to ourselves and to you 
the events in which the Society has had a part 
throughout the years since its organization. 

We have a few announcements to make. It was 
my pleasure to be present at a meeting of the State 
Medical Society’s Executive Committee this morn- 
ing, at which time it was decided to ask the State 
Medical Society of Mississippi to meet with the 
Louisiana State Medical Society next spring. The 
State Society of Mississippi will be invited to 
share the 50th Jubilee of the Louisiana State 
Medical Society next year, and we hope the 
Mississippi Society will be able to accept the 
invitation. 

We will now have the pleasure of hearing some 
music. 

(a) Musetta — Valse - Du Boheme 

(b) Fairy Roses „Colridge Taylor 

Miss May Mares 

Dr. Guthrie: I have a telegram from Dr. Oscar 

Dowling to read: 

Dr. J. Burnie Guthrie, 

President Orleans Parish Medical Society, New 
Orleans, La., 

1208 Maison Blanche. 

History and tradition present no greater lights 
than Chaille, Miles, Bickham, LePlace, DeRoaldes, 
Kohnke, Formento, Dyer, Feingold, Souchon, 
Matas, Lewis, Bruns, bom teachers and benefac- 
tors of mankind. All honor to the Orleans Parish 
Medical Society for contributions to preventive 
and curative medicine and surgery. May each 
passing year find you stronger and better. Regret 
being absent. 

Oscar Dowling. 

The subject of our next address will be “The 
Evolution of Medical Teaching in New Orleans.” 
The one who is speaking on this subject needs 
no introduction to anyone living in this city. He 
has taught nearly all of us. He has taught some 


men I have known who have lived long and useful 
lives and have passed away — Dr. Ernest S. Lewis. 

Dr. Lewis: Members of the Orleans Parish 

Medical (Society, Ladies and Gentlemen, I am very 
glad to find my name is the first on the program, 
which will enable me better to enjoy the rest of 
the proceedings. When I was asked to deliver an 
address on this anniversary, I experienced some 
difficulty in selecting a subject which would not 
be boresome to an audience so largely composed 
of the fair sex, and which would be in keeping 
with the address of Dr. Fossier, who is to talk 
on the beginnings of the Orleans Parish Medical 
Society, and its gradual development to the 
present time. I thought it might prove equally 
as interesting to you were I to give you a brief, 
cursory outline of conditions that existed at the 
time I began my medical studies, the changes that 
have taken place and some of the causes that have 
contributed to bringing them about, also, their 
effect on the exercise of the profession. 

The subject is a very broad one, and, as I have 
stated, this address that I have prepared is a 
superficial outline, otherwise it would have been 
boresome to the present audience. 

(Reads paper, which is published in fore part 
of Journal.) 

Musical selection. 

(a) Tone Picture Ferrata 

(b) Prelude C minor „..Rachmaninof 

Miss Marie Elise Dupuy 

Dr. Guthrie: The Society is very fortunate in 

having as a member a man of well-nigh univer- 
sal talent. A very few weeks ago the Board of 
Directors selected this gentlemen to arrange the 
celebration of our birthday. Everything was left 
to him to see that the audience would be on tip- 
toe to come to listen to this celebration. He has 
had to delve into the archives of the Society and 
to present a history of the Orleans Parish Medi- 
cal Society, which had to be both complete and 
condensed. I have the pleasure to introduce Dr. 
Albert E. Fossier. 

(Presents paper, published in fore part of 
Journal.) 

Musical selection. 


(a) Ave Maria Schubert 

(b) Spanish Dance - Sarasate 


Adrien Freiche 

Dr. Guthrie: About December, on the occasion 

of a banquet to which we had invited Dr. Matas 
upon his return from Europe and his election to 
the Royal College of Surgeons, Dr. Matas reminded 
us of the coming of this day and it was he who 
gave the inspiration that prompted us to come to- 


Orleans Parish Medical Society 


73 


gether tonight. Dr. Matas is in Washington, 
although his name is on the program and we ex- 
pected to hear from him. Following is a telegram 
from Dr. Matas: 

Dr. A. E. Fossier, Chairman, 

8119 Green St., New Orleans, La. 

Deeply regret that I am unavoidably detained 
here too late to participate in the glorious semi- 
centennary of our beloved Society. Though I can- 
not be with you in person I am with you in thought 
at this moment, and at this distance I am joining 
in the general rejoicing and echoing the cheers 
that will greet your recital of the Society’s fifty 
years of arduous labor and unsurpassed achieve- 
ment that have shaped the destinies of the 
0. P. M. iS. along the paths of immortality assured 
by the well earned success of the past and the 
certainty of the present we behold a future crowned 
with glory of another semi-centennial of still 
greater accomplishment in the service of our pro- 
fession of our people and of the commonwealth. 
With affectionate greetings to our assembled fel- 
lows and friends, I am yours most faithfully, in 
devotion to our dear O. P. M. S. 

R. Matas. 

Neyer is there a duty to perform in this So- 
ciety of ours that some willing hand doesn’t take 
that duty upon himself. Dr. Matas’ announce- 
ment of his delayed returned came a very short 
while ago and we called on one of our members 
who has been with us a long time and who is 
familiar with the activities of the Society, a man 
who has devoted himself to the keeping of records. 
This seems a hard and thankless task to most of 
us. We feel it requires constant devotion and zeal 
to keep them straight. This gentleman has been 
associated with the quarantine system established 
by Dr. Joseph Holt, mentioned by Dr. Fossier, 
which was copied the world over. Dr. Holt’s work 


made it possible for a system to be instituted at 
the mouth of the river which enabled boats to 
pass up the river short of the 40-day period, which 
was up to that time exacted. Dr. G. Farrar Patton 
has kindly consented to come here tonight. 

(Delivers address, published in fore part of 
Journal.) 

Musical selection. 

(a) Les Deux Serenades Leoncavello 

(b) Carme - - — Danza 

(c) Flirtation Meyfer-Helmund 

Paul Jacobs 

Dr. Guthrie: One of the most noteworthy 

questions that is raised for organized medicine to 
solve is the relation of the doctor to public life, 
and our Committee has chosen the Hon. T. 
Semmes Walmsley, a member of our Commission 
Council, to speak on this subject. There are two 
names prominent in the history of the State of 
Louisiana and the City of New Orleans in the 
last fifty years and those two names are Semmes 
and Walmsley. 

(Delivers address, published in fore part of 
Journal.) 

Dr. Guthrie: I wish to express the thanks of 

the Society to Mr. Walmsley who came here and 
took so much trouble in preparing this address 
and to assure him that we will take steps to en- 
force these medical requirements. 

Musical selection. 

Violin obligato Adrien Freiche 

Accompanists : 

Mrs. Mayer Prince Dr. Homer Dupuy 

Refreshments 


Citation of Dr. Matas. — The following citation when the 
degree of Doctor of Science was awarded Dr. Rudolph Matas 
at the 181st annual commencement of Princeton University 
so well expresses the appreciation of others outside of New 
Orleans and Louisiana that it deserves to be preserved in 
the annals of the Orleans Parish Medical Society. 

Doctor of Science. — Rudolph Matas, a graduate in medi- 
cine of Tulane University, for forty-three years connected 
with that university as a teacher of anatomy or Professor 


of Surgery, now emeritus. He is particularly distinguished 
for his researches in the surgical treatment of aneurism. 
As a surgeon his knowledge, his skill, his courage and his 
good judgment have won for him one of the highest places 
in his profession. In the great army of devoted men who 
go out to attack the many bodily ills that afflict mankind 
he is one of the leaders, followed cheerfully and with affec- 
tion by those who know the eminent qualities of his mind 
and heart. 


LOUISIANA STATE MEDICAL SOCIETY NEWS 

H. Theodore Simon, M. D., Associate Editor. 


The Journal learns with a great deal of pleas- 
ure of the appointment of one of the members 
of the Journal Committee, Dr. Hiram W. Kost- 
mayer, as Professor of Gynecology and head of 
this department in the Graduate School of Medi- 
cine of Tulane University. 

The Journal feels that this is a well deserved 
honor for a man who has labored long and faith- 
fully in the interests of organized medicine. It 
senses also that the Graduate School made a wise 
selection of one who by his skill as a surgeon and 
scientific accomplishments has made himself one 
of the outstanding gynecologists of the South. 


Louisiana State Medical Society was repre- 
sented at the recent meeting of the American 
Medical Association at Minneapolis the week of 
June 11 by Drs. Elizabeth Bass, O. W. Bethea, 
Ansel M. Caine, Geo. B. Collier, J. A. Danna, L. 
R. DeBuys, R. C. Lynch, J. H. Musser, J. T. 
O’Ferrall, E. A. Socola, and Ludo von Meysen- 
bug, of New Orleans; Dr. R. Butler of Springhill; 
Drs. Guy A. Caldwell, D. A. Huckabay, C. L. 
LaRue, and J. P. Sanders of Shreveport; Dr. 0. 
E. Denney of Carville, and Dr. Newton L. Sebas- 
tian of Ferriday. 

Louisiana physicians returned with two honors 
from this meeting; Dr. Ansel M. Caine achieved 
a well deserved recognition by being elected 
President of the Associated Anesthetists of the 
United States and Canada, and Dr. O. E. Denney 
was awarded the bronze medal in the Scientific 
Exhibit for his magnificent exhibit of colored 
plates of the lesions of leprosy. 


TRANSACTIONS OF THE MEETING OF THE 

SEVENTH DISTRICT MEDICAL SOCIETY, 
HELD IN JENNINGS. 

The Seventh District Medical Society held its 
Spring Meeting in the American Legion Hut, in 
Jennings on Thursday, June 14, 1928, at 7:30 
P. M. Considering the inclemency of the weather 
the attendance of 37 members was commendable. 

The committee in charge of the banquet and 
entertainment offered a very delightful musical 
program and splendid feast. In conjunction with 
the intensely interesting presentations this proved 
to make the meeting well worthy of praise. 

The motions for the next meeting place were 
entertained, and Opelousas was granted the privi- 
lege of election. 

The scientific program consisted of extremely 
interesting and important subjects, admirably pre- 
sented by the following very competent men; 


Dr. E. D. Fenner, New Orleans, Treatment of 
Common Fractures; Dr. Chaille Jamison, New 
Orleans, The Pleura: Remarks and Observations; 
Dr. C. S. Holbrook, New Orleans, Migraine; 
Symptoms and Treatment. 

The excellent slide demonstrations accompany- 
ing the addresses of Drs. Fenner and Jamison 
served the additional purpose of increasing the 
interest and value of these presentations. 

The presentation of a case of Splenomyelogen- 
ous Leukemia by Dr. Crawford of Lake Charles 
was very enlightening and interesting. 

The motion was made that Drs. Fenner, Jami- 
son and Holbrook be made honorary members of 
the Society, which was unanimously carried. 


Our President-elect, Dr. Frank T. Gouaux, was 
a patient at the Hotel Dieu for several days in 
June. It was necessary for the doctor to have a 
slight surgical operation performed, which h« 
stood well and convalescence was uncomplicated. 


At the last meeting of the Board of Adminis- 
trators of the Tulane University of Louisiana, the 
name of Dr. Henry Daspit was approved for ap- 
pointment as Dean of the Graduate School of 
Medicine, effective September 1, 1928. 

Dr. Daspit has been connected with the College 
of Medicine for a number of years; has been a 
member of the Executive Faculty of the Graduate 
School of Medicine since its reorganization three 
years ago, and, as one of the youngest and most 
active members, he was recommended for this 
position. He is in every way qualified for the 
honor conferred, and under his administration 
continued prosperity for the school is assured. 

Dr. Daspit succeeds Dr. E. Denegre Martin, 
who was chosen Dean at the time of the school’s 
reorganization in 1925. In relinquishing the 
deanship Dr. Martin is carrying out a policy which 
he believes for the interest of the institution, and 
that is the infusion of young blood into the ad- 
ministration of its affairs. 


RAPIDES PARISH MEDICAL SOCIETY. 

At a recent meeting of this society there was 
introduced and passed a resolution that the Presi- 
dent appoint a committee to present to the society 
suitable expression of the society’s appreciation of 
the public record of two of its members, viz: Dr. 
Jno. M. Thomas, Superintendent of the Central 
Louisiana Hospital for the Insane, and Dr. G. M. 
G. Stafford, Superintendent of the State Colony 
and Training School. 


Louisuma State Medical Society 


75 


Dr. Thomas has been at the head of the Cen- 
tral Louisiana Hospital for the Insane since 1909. 
The institution has grown from a rather crude 
beginning, when it housed just four hundred in- 
mates and performed the simple function of deten- 
tion and care with the mere necessities of life, 
with no attempt at medical relief, to a modern 
hospital for those mentally sick, giving scientific 
care to nearly thirteen hundred insane. 

When Dr. Thomas assumed charge of this insti- 
tution there was no effort to study and classify 
the cases so that appropriate measures might be 
taken; there were no staff meetings, and it might 
be said that there was not a staff, and laboratory 
facilities were unknown. Today, there stands a 
modern institution for the care of the insane, 
erected by the money of the State, it is true, and 
its management properly supervised by citizens 
appointed for that purpose, but the whole devel- 
opment of the hospital, its policies, its spirit of 
care and kindness, have all been inspired by the 
man who has served as its superintendent for 
nearly twenty years. During that time, his public 
records stamps him a kindly man, an efficient man, 
and, above all, a conscientious public official. 

Upon the death of our late member. Dr. Watt 
Evans, Superintendent of the State Colony and 
Training School, Dr. G. M. G. Stafford, long a 
member of this society, was appointed to the 
place. This institution is but a few years old, the 
State’s care of the feeble minded is a new work 
in Louisiana, and the work which Dr. Evans 
started has been carried on ably under its present 
management; there are few medical men in this 
or any other State who have been given the prob- 
lem of the feeble minded serious study, and the 
State is fortunate now to have the medical men 
in charge of the work, who are now there. In 
the short time he has been there. Dr. Stafford has 
shown a keen interest and kindly sympathy in his 
work and no man could have made a better record 
with the limited facilities and funds furnished for 
the purpose. 

Your committee believes the above poorly but 
truthfully expresses the opinion of the members 
of this society. 

M. CAPPELL, 

K. RAND, 

Committee. 


THE SIXTH DISTRICT MEDICAL SOCIETY. 
To the Medical Profession of the Sixth Congres- 
sionel District — Greetings : 

It may not be amiss to state that the Tenth 
Spring Meeting of this society, which was to have 
taken place last April in Baton Rouge, was, for 
obvious reasons, pretermitted to June in defer- 
ence to the meeting of the State Medical Society. 


This meeting’s scientific program will consist 
of a symposium on Asthma and Hay Fever, led 
by Doctors F. W. Scheppegrell and N. F. Thi- 
berge of New Orleans, with stereopticon views, 
followed by a number of other papers, incidental 
hereto. I would be pleased to receive the name 
as well as the title of the paper that any of you 
may care to read (relative to the aforementioned 
subject matter, of course,) as soon as possible, so 
that it may be printed in the official program. 

At 1 P. M. one of those delicious luncheons 
for which our hosts are famous. 

Firmly believing that a “Woman’s Auxiliary” 
to this society would be of immeasurable assist- 
ance, vast benefit, boundless good and unusual 
interest, it is my purpose and I very much desire 
to distinguish my term of office as also to blaze 
the way for other medical societies in the State 
by organizing and launching such an auxiliary at 
THIS meeting, and with that end in view may I 
urge you to bring along the ladies of your imme- 
diate family with the suggestion that this feature 
take place immediately following the luncheon. 

This being the Annual Meeting and Election of 
Officers, may I beseech a full attendance, thus 
enabling us to live up to our reputation and up- 
hold our rank in the medical world. 

If YOU are a member of your Parish Society 
or in GOOD standing with the State Medical 
Society, COME even though you have never met 
with us — COME, we WANT you, we need YOU, 
and believe me, you will enjoy the meeting and 
yourself. 

Now, Doctor, please memorize the following: 

Occasion — ^Tenth Spring Meeting of the Sixth 
District Medical Society. 

Place — City of Baton Rouge, La. 

Location — Our Lady of the Lake Sanitarium. 

Day and Date — Wednesday, June 27th, 1928. 

Time— 9:30 A. M. SHARP. 

With expressions of regard and gratitude for 
the honors conferred on me by the society. 
Respectfully, 

A. G. MAYLIE, M. D., 

President. 


NEW ORLEANS OPHTHALMOLOGICAL AND 
OTOLARYNGOLOGICAL SOCIETY. 

The scientific meeting of the New Orleans 
Ophthalmological and Otolaryngological Society 
was held at the Eye, Ear, Nose and Throat Hos- 
pital on Thursday, May 17, 1928. Dr. Buffington 
was appointed Chairman of the meeting. 

Dr. Joachim presented the following two cases: 

Case No. 1. A man with carcinoma of the 
larynx on whom he did a laryngotomy May, 1920, 
followed by radium therapy in which there ap- 


76 


Louisiana State Medical Society. 


peared to be no recurrence, although the patient 
visited him two days ago with a complaint of a 
cold in the throat associated with hoarseness of 
three days’ duration. One brother died of carci- 
noma of the larynx, sister died of carcinoma of 
pelvis, another brother sick with carcinoma of 
the stomach. On inspection of the larynx a whit- 
ish gray band is seen crossing the anterior com- 
missure of the larynx with slight pedema of the 
arytenoids and partial fixation. A scar in the 
midline of the neck is seen on inspection, the 
result of the external laryngotomy. 

Case No. 2. A man, aged 46 years, who five 
years ago appeared for treatment for a carcinoma 
of the base of tongue size of thumb after being 
reported by a surgeon as being inoperable. Ap- 
plications of radium needles and roentgen 
therapy was given for several months with only 
softening of the tumor. He was sent to the physi- 
cian who was treating him in Meridian, Miss., 
who continued the roentgen-ray and radium 
therapy, and today he is preaching to his congre- 
gation and feeling well. 

Dr. Allen showed a patient with tuberculosis of 
the uveal tract which simulated interstitial kera- 
titis, which had been under treatment and obser- 
vation twelve months, in whom the vision im- 
proved from 20:200V to 20:50V and the opacities 
of the cornea disappeared, and the two exudative 
masses of the vitreous shrunk considerably. The 
Wasserman was negative. Patient become worse 
in the beginning under anti-luetic treatment. In 
the discussion the tuberculin test and tuberculin 
therapy were suggested. 

Dr. Brown presented two patients with acute 
glaucoma improved by means of a new operation 
in which he describes the technique as follows: 
The conjunctiva is first anesthesized either with 
holocain or cocain. The bulbar conjunctiva is 
gi’asped with a fixation forcep at a point 6mm. 
from the corneo-scleral limbus either in the inner 
or outer canthus. A hypodermic needle is in- 
serted with its point directed toward the limbus 
and a solution of novocaine, 2 per cent, and 
adrenaline chloride, 3 minims, to the syringe full 
are injected so as to create a bleb. A Ziegler 
knife needle with its blade held upon the flat is 
inserted within the center of the bleb and carried 
sub-conjunctively to a point 1mm. anterior to the 
limbus the sclera is perforated and the anterior 
chamber is entered. The knife is now turned so 
that its cutting edge is in contact with the iris 
fibres. The iris is divided at its root. The knife 
is tneii turned upon the flat surface and removed. 
The advantages are: to furnish immediate relief 
from pain, to diminish the intra-ocular tension, to 
prevent permanent blindness from increased ten- 
sion, to keep the patient quiet until a more per- 
manent treatment can be prescribed. 


Dr. Hume presented a case of herpes zoster 
oticus from involvement of the geniculate gang- 
lion because of its rarity. The child, aged 6 
years, complained of severe pain over the right 
mastoid for five days, followed by a sudden 
paralysis of the facial nerve, with no changes of 
taste or involvement of the nerves of salivation. 
The herpetic lesions involved the auditory canal 
cavum chonchea with post-auricular glandular en- 
largement. It was of interest to note the absence 
of involvement of the chorda tympani nerve and 
the sympathetic fibres to the salivary glands, and 
in the discussion a thorough anatomical discrip- 
tion of the geniculate ganglion and the fibre en- 
tering into its formation was given so as to explain 
this phenomenon. 

Dr. Perdue presented a case of optic atrophy 
in a man with general paresis, a negative Argyl- 
Robertson pupil, almost complete contraction of 
peripheral fields for all colors, a visual acuity of 
20:15 V., and unable to see large objects such as 
large buildings. This strange visual defect was 
accounted for by a few of the central fibres of 
the optic nerve in the maculo-papular bundle not 
being affected and with a small area of central 
vision the size of a dime remaining. In the dis- 
cussion, the question of the etiology of the optic 
was brought out, but the cause was not decided 
as to whether the atrophy was due to the lues or 
the arsenical therapy. 

Dr. Allgeyer presented a case of persistent re- 
current iritis of nine years’ duration with infec- 
tion of the prostate previously treated by several 
ophthalmologists. Teeth, tonsils, sinuses, and 
other foci of infection were negative. No tuber- 
culine test was made. Patient recovered after 
three doses of diphtheria antitoxin. There was 
some discussion as to the possibility of the case 
being tuberculous, although it was self-evident 
that after the injections of the foreign protein in 
which the reticulo-endothelial system was brought 
into play. It resulted in the marked improvement, 
which further confirmed the prostate as the focus 
of infection producing the iritis. 

WILLIAM A. WAGNER, 

Secretary-Treasurer. 


NEW SOCIETY. 

At a comparatively recent meeting, the New 
Orleans Gastro-Enterological Society was organ- 
ized. The following officers were elected: Dr. 
Sidney K. Simon, president; Dr. J. A. Storck, 
vice-president; Dr. A. L. Levin, secretary-treas- 
urer. The object of this society shall be the pro- 
motion of the study of normal and pathological 
conditions of the digestive tract, and its allied 
organs, as, likewise, nutrition and metabolism. 


Louisiana State Medical Society. 


77 


INTERSTATE POST-GRADUATE ASSOCIA- 
TION WILL MEET IN ATLANTA. 

For the first time in the South there will be 
held a medical association whose proceedure is 
unique and of remarkable interest. 

The Interstate Post-Graduate Medical Associa- 
tion of North America will meet in Atlanta, Ga., 
October 12th to 19th, inclusive. This association 
in 1926 met in Cleveland, Ohio, where nearly 
5,000 practicing physicians were registered. At 


the Kansas City meeting last October 5,200 were 
registered. 

Those who come to this remarkable sort of 
medical meeting will really be given a post-gradu- 
ate course by the leading medical men of this 
country and abroad. The daily meetings are 
held from 7 A. M. to 1 P. M., from 2 to 5 P. M. 
and from 8 to 10 P. M. Every one who has at- 
tended these meetings has been amazed by the 
magnitude of the work done, by its quality, by 
the number of distinguished guest and by the re- 
markable interest aroused. 


MEDICAL WRITING. 

In this connection may I remind you that, 
whatever work we may do, either clinical 
or investigative, it will do little general 
good and vdll lose much or almost all of its 
effect unless the noteworthy part of it is 
promptly and well reported in the medical 
press, which itself indeed cannot grow and 
prosper unless the profession gives it the 
material by which it can live and grow. We 
Southerners have always been too loath to 
go into print and have hence woefully 
sinned in not putting on record the glori- 
ous history of our ancestors and our section 
and have let others too often run off with 
our laurels. And we seem to be just as 
backward in reporting our medical work. 
Certainly until we develop the habit, as our 
Northern brothers so wisely have, of thus 
giving to the public and the future the re- 
sults of our studies, they will remain almost 
useless to our profession, and the world will 
not know what we are capable of or realize 


the good work that is being done South of 
the Mason and Dixon line. 

Let then every one of us, resolve not in- 
deed to get that sad disease, the furor scri- 
bendi, which tempts a man to vomit forth 
incessantly over a suffering public the undi- 
gested results of careless observations and 
poor thinking just for the sake of being in 
print, but to force ourselves to observe and 
record so accurately the results of our work 
that we shall have material of real value 
which we shall be careful to report fully in 
the journals, and which shall be not only a 
credit to us, but an asset to our section and 
which will enable the medical world to see 
what the sons of the South are doing for 
the advancement of our science. In the last 
anaylsis, it depends upon the interest and 
energy of Southern physicians to put over 
these things which I have suggested, and I 
leave the matter in your hands, feeling sure 
that such a cause cannot fail to elicit your 
enthusiastic interest and your untiring and 
persistent support. — Minor, C. L. : South. 
M. J., 18:1, 1925. 


MISSISSIPPI STATE MEDICAL ASSOCIATION NEWS 

J. S. UUman, M. D., Associate Editor. 


The regular quarterly meeting of the North- 
east Mississippi Thirteen Counties Medical Society 
was held at Houston, Miss., June 19, 1928, when 
the following program was presented: 

1. Angina Pectoris, an Echo, Dr. G. S. Bryan, 
Amory. 

2. A paper. Dr. S. H. Hairston, Meridian. 

3. Urinary Obstructions, Dr. L. B. Morris, 
Macon. 

4. Early Diagnosis of Pulmonary Tuberculo- 
sis, Dr. W. A. Toomer, Tupelo. 

5. Roentgen-ray and Radium Therapy, Dr. J. 
R. Williams, Houston. 


THE EX-PRESIDENTS CLUB. 

One of the most important incidents of the 
State Association convention is the meeting of 
the Ex-Presidents. There are now twenty-five 
living Ex-Presidents, of whom fifteen attended 
the Meridian meeting. One, Dr. S. W. Johnston, 
was called away on business. The following at- 
tended the club dinner: P. W. Rowland, W. W. 
Crawford, D. W. Jones, D. J. Williams, J. S. Ull- 
man, I. W. Cooper, T. M. Dye, F. J. Underwood, 
J. W. Barksdale, Henry Boswell, W. A. Dearman, 
G. S. Bryan, T. E. Ross, John Darrington. The 
names are given in order of “age” of service. 

Dr. Cooper was the host of the Club, and 
served an excellent dinner at the Wiedman. The 
Club was called to order by the Secretary, Dr. 
Jones, who read the list of Ex-Presidents. Dr. 
Rowland, being the “oldest” member in point of 
service, was asked to preside. He had the Club 
to stand a moment in silent reverence to the 
memory of our deceased brother. Dr. J. M. 
Buchanan, who died since the last meeting of the 
Club. Dr. Cooper then gave a short sketch of 
the official life of Dr. Buchanan, and paid a beau- 
tiful tribute to his long life of service in the Asso- 
ciation. 

The Secretary read a letter from Dr. J. W. 
Young, the oldest living Ex-President, expressing 
his regrets over his inability to attend the meet- 
ing. The veteran doctor has recently suffered a 
stroke of paralysis, and is confined to his bed. 
The Club instructed the Secretary to send a tele- 
gram of love and sympathy to Dr. Young. (Later 
a similar telegram was sent by the Association.) 

By request. Dr. Rowland gave a short sketch of 
his connection with the Association. He joined 
the Association at Meridian forty-five years ago, 
and has missed only two meetings since. He also 


joined the Southern Medical Association when it 
was organized and has missed but few of their 
meetings. He is also a member of the A. M. A. 
for many years, and has attended several of their 
meetings. 

At this point, the secretary called attention to 
the fact, by contrast with this wonderful record 
of loyalty, that several of the Ex-Presidents had 
attended but few meetings since their terms as 
Presidents expired. Dr. Barksdale took occasion 
to give a severe castigation to those officials who 
seemed to appreciate this honor so lightly, and 
made a beautiful talk on the value of the influ- 
ence which the Ex-Presidents of this Association 
might exert on the younger members, and thus 
exalt and honor the office of President. 

Dr. Crawford, as the next oldest in point of 
service, was then called upon and gave many 
reminiscences of some of the men who were the 
leaders when he served as President. Dr. Dar- 
rington, the youngest member, was then called 
upon and expressed his appreciation of the honor 
of being a member of this Club, and declared he 
would do everything in his power to uphold the 
dignity of the high office in which he had just 
served. 

Dr. Rowland, who has attended over forty 
meetings of this Association, here issued a chal- 
lenge to the members of this Club to meet him 
each year for the next ten years, which challenge 
was accepted with enthusiasm, and the club ad- 
journed. 

D. W. JONES, 

Secretary. 

The regular monthly meeting of the Isaquena- 
Sharkey- Warren Counties Medical Society was 
held June 12th in Vicksburg. The program con- 
sisted of the following: 

1. Certain Lesions of the Cervix Uteri and 
Their Treatment, Dr. W. H. Parsons. 

2. Sinus Disease in its Relation to General 
Surgery, Dr. G. M. Street. 

This society has an unusually efficient secre- 
tary. His notices are always worth while. Re- 
cently he has adopted the plan of carrying some 
very pithy extracts on the back of his letters and 
circulars. Here are two from his last letter. 
Perhaps some of the other secretaries might want 
to adopt this plan or something like it. 

Dr. E. H. Jones — “Ethical Advertising. The 
Code of Ethics states most forcibly that no physi- 
cian shall cause to be published, or even inspire, 


Mississippi State Medical Association 


79 


an article laudatory to himself. All of us will 
readily and heartily agree to this, but would not 
a form of advertising that would react to the 
benefit of the whole profession be entirely ethi- 
cal? Many years ago the banks were extremely 
dignified in their advertising. At the same time 
large and impressive advertisements of “get-rich- 
quick” companies fleeced the public out of millions 
of dollars. The banks have since changed their 
policy * * * by educating the public, have per- 
formed valuable service, teaching them how to 
take care of their money. * * * Might we not be 
furnishing our ideal of service to mankind if, 
through ethical advertising, we attempted to bet- 
ter educate the public how to conserve health and 
to avoid charletans, quacks, and patent medi- 
cines?” 


PUBLIC HEALTH DEPARTMENT 
ATTENTION! 

Colored Customer: “Ah, want a quote of sanc- 
tified milk.” 

Storekeeper: “What you-all mean is pacified 
milk.” 

Customer: “Look heah, small one, when Ah 
needs inflammation, Ah’ll specify.” — Gateway to 
Health. 


The State Board of Health in its weekly health 
suggestions has lately been devoting its attention 
to the fight against cancer. We should like to 
invite your attention to two of these that are 
particularly good. 

“THE FAMILY DOCTOR IN CANCER.” 

“The family doctor is the key man in the con- 
trol of cancer. 

“It is to him that a person should go for diag- 
nosis and treament. 

“If the family physician is not certain of the 
diagnosis, he should not wait, but refer the 
patient to some other physician or to a hospital 
or clinic where special facilities exist for the ex- 
aminations which are required. 

“It is no reflection upon the family physician 
when he cannot himself make a diagnosis in can- 
cer, for the disease takes so many forms and af- 
fects people in so many ways that it is sometimes 
impossible, even with the best equipment, skill, 
and experience, to be certain of the trouble. 
There is an old saying and a true one to the effect 
that the more simple the diagnosis the more fatal 
the case. The reason for this lies in the fact that 
advanced cases of cancer present symptoms which 
are unmistakable, whereas newly formed cancers 
in certain locations may present few or no symp- 
toms. 


“The family doctor in cancer should be the 
patient’s guide, philosopher, and friend. He is 
familiar with all the resources in his region of 
the country which can be turned to the advantage 
of his patients. He should be suspicious of can- 
cer upon the slightest evidence, and he should be 
firm in the instruction he gives as to treatment. 
Being a practitioner of medicine and not a sur- 
geon, he may not be able to perform the opera- 
tion, if one is required, but he should know the 
qualifications of those who can do so -with the 
greatest skill. He should be aware of the pitfalls 
which lie in the field of quackery, and be able to 
guide his patients away from them.” 


“DELAYS ARE FATAL IN CANCER.” 

“It has been well said that every cancer is at 
first a miniature tumor and at that time but little 
more difficult to cure than a splinter or the sting 
of an insect. 

“If a little cancer was as painful as a sting, 
many people would go promptly to a physician, 
and so be made well. But at first there is no 
pain or inconvenience. The symptoms develop 
gradually. Suspicion is not aroused that there is 
anything much the matter. 

“On the theory that the trouble is trifling and 
will disappear if left alone, the patient delays 
calling in medical help. It is surprising to find 
how many persons have long been aware that 
something was wrong with them before they have 
gone to a physician about it. But every day 
counts. When at last something has to be done, 
it is often too late. 

“It is desirable to treat all diseases in their 
early stages, but in no affection is it more neces- 
sary than in cancer. The danger is like that of a 
fire. At first there is but a spark which can 
readily be extinguished. As the flames spread, 
the fire becomes more and more unmanageable. 
At last a conflagration develops and extinction is 
no longer within human power. 

“What should be done when a person thinks he 
or she has a cancer is well illustrated by the 
case of an old lady who is now reaching a ripe 
old age in New England. Many years ago her 
suspicion became aroused that she had cancer. 
Within an hour she was at the hospital demand- 
ing an examination. The next day she was oper- 
ated upon for cancer of the breast. She has 
been well satisfied with the results and has ex- 
plained to hundreds of women that cancer can 
be cured if taken in time.” 


PREVENTION AND CURE OF TUBERCULOSIS 
The Appendix to the Congressional Record of 
May 23, 1928, pages 9974-8 contains a paper 
carrying the above title. This was presented by 


80 


Mississippi State Medical Association 


Senator Earle B. Mayfield of Texas with the 
request that it be printed in the Record. “There 
being no objection, the paper was ordered to be 
printed.” It does not appear in this Record how 
the Senator is qualified to pass on the worth 
of such a paper. 

It may be interesting to quote a few gems from 
this paper. 

"DEFINITION 

“TUBERCULOSIS IS A SLOW DECAY OF VITALITY. 

“That is to say, a slow and continuous decay 
of the vital functions— respiration, circulation, 
nutrition, and assimilation — a disease in which 
the decay of the body exceeds the growth or re- 
pair. 

“It is not hereditary or contagious; no child 
was ever born with tuberculosis, but the parents 
may hand down to their progeny the predisposi- 
tion or tendency to contract the disease on ex- 
posure to certain conditions of environment. 

"CAUSES 

“There are four principal causes, all of which 
are capable of being removed; all are acquired, 
not inherited. And here it may be laid down as 
an axiom that if the cause of a disease can not be 
found and wholly or partially removed, no per- 
manent cure can be made, the disease will prevail 
in spite of everything that can be done. 

"FIRST CAUSE. 

“Neglected or badly treated cases of pneumonia 
or bronchitis very frequently degenerate into tu- 
berculosis, and the number of such cases is legion. 

•‘SECOND CAUSE 

“Vaccination or inoculation of the body with 
animal matter or poisons (ptomaines) which im- 
pair wholly or partially the function of the lym- 
phatic glands whose function is to take up the 
waste and dead matter and eliminate it from the 
system. 

"THIRD CAUSE. 

“A deficiency of iron in the blood. Such per- 
sons are pale, anemic, weak, flat chest, soft mus- 
cles, insufficient lung expansion, easily fatigued, 
lack endurance, etc. Iron is absolutely neces- 
sary for our very existence. We receive it in 
our food, which can never be too rich in that 
metal. A person can never have too much iron 
in his blood; it maintains health and strength. 

"FOURTH CAUSE. 

“The use and abuse of alcohol in any form has 
been a prolific cause of tuberculosis, especially 
among the aboriginal inhabitants, the Indians. 
Alcohol has a strong affinity for water, it dries 
up the brain, and nerves, causes sclerosis of the 
liver, jaundice, dyspepsia, and all the disastrous 
results that flow from them, and very frequently 
terminates in tuberculosis. 


"CHEMICAL ANALYSIS OF THE ‘BACILLI’. 

“Put a quantity of the dried sputum prepared, 
as already described, into a suitable glass vessel 
and pour on 5 or 6 ounces of boiled distilled 
water acidulated with nitric acid in order to insure 
the decomposition of any carbonates that may be 
present and carefully filter. The filtrate — the li- 
quid which passes through — contains in solution 
all the sulphates, chlorides, phosphates, and ni- 
trates of the five metals which enter in the com- 
position of the human body — -viz, potassium, cal- 
cium, sodium, magnesium, and iron — and the dark 
or black substance on the filter is tuberculin, the 
organic portion of the heteroplasm. 

“To the filtrate add carefully drop by drop, 
stirring with a glass rod, a solution of barium 
nitrate; a white precipitate of barium sulphate 
will be thrown down characteristic of sulphur. 
Filter and set it aside for subsequent examina- 
tion if deemed necessary. The filtrate is now 
free from all sulphates. The next step is the 
removal of the calcium which would interfere 
with the subsequent examination for magnesium; 
therefore add drop by drop, stirring always with 
a glass rod, a strong solution of oxalic acid, which 
will throw down a white precipitate of oxalate of 
calcium (lime), which filter off as before. The 
filtrate now contains the salts of four metals — 
potassium, sodium, magnesium, and iron. 

“Now add a solution of silver nitrate; a pale yel- 
low or dirty white precipitate of the chloride and 
phosphate of silver will be thrown down, and to 
this add strong nitric acid, which will dissolve the 
phosphate but not the chloride. Remove the pre- 
cipitate by filtration as before, dry it and expose 
it to sunlight, when it will turn black, highly 
characteristic of chlorine. The filtrate now con- 
tains only phosphates and nitrates. Now add 
more nitrate of silver, when a yellow precipitate 
of the orthophosphate of silver characteristic of 
phosphorus will be thrown down, which remove 
by filtration as before. 

“The sulphates, chlorides, and phosphates have 
now been decomposed and nitrates remain in their 
place; calcium has been removed and sulphur, 
chlorine, and phosphorus shown in the precipitates 
which can now be dried, weighed, and estimated 
in the usual way if a quantitative analysis is re- 
quired. 

“The filtrate — now a solution of nitrates — is 
now to be evaporated to a dryness and heated to 
redness or as long as nitrous fumes are given off, 
when there ■will remain the oxides of the four 
metals — potassium, sodium, magnesium, and iron. 
The first two are soluble in water, the other two 
are not. Dissolve in distilled water and separate 
by filtering. The filtrate now contains only po- 
tassium and sodium hydrates. Wash off the mix- 
ture of magnesium and iron hydrates on the filter 


Mississi^i State Medical Association 


81 


with sufficient nitric acid to dissolve them, which 
reduces them again to nitrates, divide the solution 
into two equal parts, to one add ferrocyanide of 
potassium. A white precipitate falls and rapidly 
becomes blue by the absorption of oxygen of the 
air, intensely characteristic of iron. To the other 
add chloride of ammonium, aqua ammonia, and 
phosphate of sodium; a white precipitate falls 
off the double phosphate of magnesium and am- 
monium having the composition of MgN H 4 PO4 
— highly characteristic of magnesium. There is 
no direct test for this metal, but only by forming 
double salts as above. 

“To tbe balance of the filtrate which now con- 
tains only potassium and sodium hydrates, add a 
few' drops of hydrochloric acid, thus converting 
them into chlorides. Now' add a drop or two of 
the perchloride of platinum, a yellow precipitate 
of the double chloride of platinum and potassium 
having the composition of PtCl 42 KCL will be 
produced characteristic of potassium. 

“There now remains in the filtrate only chloride 
of sodium — common salt — for the sodium, of 
which there is no chemical test or reagent. A 
drop of the solution imparts an intensely yellow 
color to the flame of an alcoholic lamp, distinctly 
characteristic of his metal, and the spectroscope 
gives the distinctive yellow line w’hich distinguishes 
this metal from all others. 

“Here ends the chemical analysis of these 
minute crystals of the salts which enter into the 
composition of the human body — the first and the 
only one ever made or on record in any country 
in the wmrld. 

“These crystals of inorganic matter, errone- 
ously believed to be animacula, that is, living mi- 
croscopic germs consuming and gnawing at the 
very vitals of the unfortunate victims, have caused 
an incalculable amount of trouble and distress to 
millions of our people, and as a result of which 
very many of them fill premature graves.” 

This paper was written by Dr. John Morrison 
of San Antonio, Texas. The following is a letter 
from the American Medical Association that will 
throw further light on the worthy: 

“Dear Dr. Ullman: 

“Doubtless the Dr. J. Morrison of San Antonio, 
referred to in your letter of June 4, is Joseph 
Morrison, who was born in 1848, graduated by 
the University of Toronto Faculty of Medicine in 
1872 and licensed to practice in the District of 
Columbia in 1896. So far as we know, Morrison 
is not licensed to practice elsewhere in the United 
States, even in Texas, where he now resides. Mor- 
rison’s name has not appeared in the American 


Medical Directory for many years, because, for a 
long time, he dropped out of sight. 

“It would appear that Morrison is either one 
of these wrong-headed individuals who, on gen- 
eral principles, is opposed to the established order, 
whether it be science or religion, or who is in his 
dotage and riding a fad. About two years ago 
Morrison was boosting what is essentially an 
electric nostrum, namely: ‘Echinacea’. 

“Information in our files shows that Morrison 
is an anti-germ and anti-vaccination faddist. It 
seems that some time ago he published a book 
entitled ‘Tuberculosis — Its Causes, Nature, Pre- 
vention and Cure,’ with the subtitle, ‘The Death 
Blow to the Germ Theory — A Chemical Analysis 
of the so-called “germs”. The dangers of vacci- 
nation exposed.’ In view of this, we were not 
surprised to learn some time ago that Morrison 
is vice-president to the ‘American Liberty League.’ 
This, as you probably know, is a preposterous 
organization made up of quacks, near-quacks and 
faddists, whose particular bugaboo is vaccination. 
We enclose an article on the ‘league’, which you 
may find of interest in this connection. 

“Very sincerely yours, 
AMERICAN MEDICAL ASSOCIATION. 


President Frizell announces the following com- 
mittee appointments : 

STANDING COMMITTEES. 

Public Policy and Legislative — D. W. Jones. 
Medical Education — P. W. Rowland, T. E. Ross, 
Sr., G. E. Adkins. 

To attend State Teachers’ Association — Henry 
Boswell, John C. Culley, F. J. Underwood. 

On Publication — J. S. Ullman, B. S. Guyton, 
T. M. Dye. 

On Scientific Work — L. S. Lippincott, W. H. 
Anderson, T. M. Dye. 

On Necrology — W. G. Gill, W. L. Little, M. W. 
Robertson. 

On Hospitals — 0. N. Arrington, E. F. Howard, 
S. H. Hairston. 

CHAIRMEN OF SECTIONS. 

Medicine — W. A. Dearman. 

Surgery — W. W. Crawford. 

Hygiene — C. C. Applewhite. 

Eye, Ear, Nose & Throat — E. Leroy Wilkins. 


82 


Mississippi State Medical Association 


TRI-COUNTY NEWS. 

The Tri-County held its second quarterly meet- 
ing of the year and its first under its recently 
issued charter, which was granted since the soci- 
ety now embraces the counties of Walthall and 
Lawrence. 

The society met in Hazlehurst with a very good 
attendance. 

Dr. Chas. L. Eshleman of New Orleans, the 
guest of honor, presented a very interesting paper 
on Pernicious Anemia, giving case reports of two 
years, standing both from private and Touro rec- 
ords, showing the various blood pictures, with 
and without the liver diet. Lantern slides greatly 
increased the interest. 

Dr. O. N. Arrington reported the meeting of 
the State Medical Association to the local members 
with comments on its program and good fellow- 
ship. 

Dr. L. W. Brock of McComb presented a paper 
on Broncho-Pneumonia in Measles. 


Dr. W. H. Frizell, the recently elected Presi- 
dent of the State Association expressed his ap- 
preciation of his promotion to this high office and 
spoke of some of the policies of his administra- 
tion. 

The society adjourned to meet September 11, 
in Brookhaven. 


Dr. W. W. Weathersby of Fair River, Lincoln 
County, Mississippi was found dead in his pecan 
grove near his residence on May 19, 1928. It is 
presumed that he succumbed to a heart' attack as 
he had suffered from some form of cardiac trou- 
ble for many years. 

He was born in Lawrence County, Mississippi, 
May 19, 1868. He was a son of the late Dr. 
William Weathersby. He practiced for a while 
in McComb and had served as surgeon to differ- 
ent saw-mills in his county, but for several years 
past he had retired from active practice. 


Dr. J. H. Johnson is still in very poor health 
due to a weak right heart with hypertension. 


STATESMEN AND MEDICINE 

In the above section of the Journal will 
be found quotations from a most remark- 
able paper which appeared in a recent num- 
ber of the Congressional Record. This 
gives rise to certain reflections as to the at- 
titude of “statesmen” toward public health 
and medicine. Senator Mayfield is not the 
first to espouse the cause of some crank or 
charlatan in Congress. Most of us remem- 
ber very well when Congress instructed the 
United States Public Health Service to 
undertake an unnecessary investigation of 
Freidman’s so-called turtle serum. 

The higher type of physician has long 
questioned the wisdom, the necessity, or the 
advisability of upsetting the management of 
our eleemosynary institutions every time a 
new governor comes into office. It is a sad 
commentary on our civilization that institu- 


tions for the lame, the halt, the blind, the 
insane, and the suffering should be consid- 
ered as nothing more than a means of pay- 
ing off minor political obligations. This 
state of affairs is not a new thing nor is it 
confined to any one political faction or to 
any particular State. 

In this connection we would call attention 
to the fact that Dr. Oscar Dowling is recog- 
nized not only in Mississippi, geographically 
the sister State of Louisiana, but throughout 
the whole United States, as one of the out- 
standing figures in Public Health work. We 
do know that in the past tweny-five years 
the State Board of Health of Louisiana has 
been brought up to a standard equal to that 
of any in the United States. We cannot be- 
lieve that the medical profession would have 
supported Dr. Dowling so solidly during all 
of these years had there been any question 
as to his honesty and efficiency. — J. S. U. 


BOOK REVIEWS 


Reflections : A Book of Poems: By James Thomas 
Nix, M. D., LL. D. New Orleans, Walter 
Neale. 1928. 

Members of our profession have distinguished 
themselves in the fields of art and literature. 
Aside from their active and self -sacrificial work 
in human salvage, these gifted ones have, as an 
“entr’acte,” cultivated the Muses and enriched the 
world with artistic creations. But, when “one of 
our own” leaves the beaten paths of daily routine 
to climb the heights of Parnassus, it is time to 
pause and take notice. 

All real art is largely self-expression. Our 
“Doctor Poet” could not escape the myriad influ- 
ences and human contacts of his calling. Thus it 
is we find a personal note in these “Reflections.” 
And therein lies the special charm. Such themes 
as “Your Doctor; My Patients; When Doctors 
Disagree; King of Sleep; Cries; Death;” are tinc- 
tured with the Aesculapian outlook on life. Inter- 
weaving this whole collection of verses is an all- 
embracing sympathy, deep-souled pity, kindly 
humor, the love of suffering humankind. 

“The Doctor calls 
To nurse near by; 

Unmask her face. 

It’s a boy!” 

Here is serio-comic obstetric experience from 
“Cries,” a startling, realistic bit of verse. In 
“Doctors Disagree,” there is well-deserved banter 
at what we know to be pitifully true. One of the 
thrusts we quote: 

“When I was fat, I should dry out. 

When I was thin, I must get stout, 

I know great men will disagree — 

But, what a mess they’ve made of me.” 

Only a scientific mind could with poetic quality, 
and yet not transcending the truth, essay this 
definition of life: 

“Though only a little protoplasm, 

A jelly-like single cell. 

Alive and moving, how and why? 

’Tis only God can tell.” 

In the “River of Tears” we find the matter and 
form of genuine poetry. There is sombre truth 
in these selected stanzas: 

‘‘So tears were created by God, I know. 

That burdened hearts might overflow. 

They wash away all cares and grief. 

And bring to every one relief.” 

With the keen appreciation of a physician who 
knows the potency of sleep, in “The King of 
Sleep” there is a brilliant display of imagination. 


yet, the whole is rock-ribbed with the healing art’s 
background. 

“Science found my hiding place 
And to the world revealed, 

They found me in the poppy plant. 

^ ^ ♦ ’I* 

They make me in a tablet form. 

Or shape me to a pill. 

Again I’m in a glass syringe. 

They do just what they will.” 

If we could usurp journal space we would for- 
bear from disjointing some of these real poetic 
utterances. The reviewer is limited to culling 
what impresses him as examples of genuinely good 
verse. Many excellent lyrics abound in this 
volume for the delectation of those who love the 
lilt and cadences of poetry. Dr. Nix, the poet en- 
grafted upon the doctor, gets away when he 
chooses from the medical environment, and with 
larger and intenser vision of life, attunes his 
lyre to sing of themes forever new, such as “LOve, 
The Sun, Hearts, Hope, Faith,” and kindred in- 
spiring subjects. With a natural gift for rhyme 
and rythm he runs the gamut of descriptive and 
narrative poetry, the quartrain, the lyric, and 
sonnet. 

Surely, the talent, versatility, and idealism, 
displayed by the author of “Reflections,” merits 
the unfeigned admiration, sincere praise, and 
heartiest congratulations of his confreres through- 
out the Pelican State. 

Homer Dupuy, M. D. 


Diabetes: Its Treatment by Insulin and Diet: A 
Handbook for the Patient: By Orlando H. 
Petty, A. M., M. D., F. A. C. P. Ulus. 4th 
ed. Philadelphia, F. A. Davis Company. 
1928. pp. 152. 

One of the few fighters in the great "War 
awarded the Congressional Medal of Honbr given 
by Congress for exceptional braveryi in . battle 
and one of the few medical men who^has ever 
held this honor. Dr. Petty has shown his bravery 
in civil life as well as in war by adding, to the 
long list still another little handbook on diabetes 
for the patient. However, in going over the 
book, noting how carefully it has been prepared, 
how much real and valuable information it con- 
tains and how well all the salient features of 
diabetes are presented in a manner which the 
tyro is thoroughly able to understand, one is able 
to appreciate the book to such an extent that 
the wish arises that there might be a somewhat 
similar honor which could be awarded the author 
by the medical profession for exceptional medical 
accomplishment as well as the one for bravery. 

J. H. Musseb, M. D. 


84 


Book Reviews 


Diagnosis and Treatment of Diseases of the 
Lungs: By Frank E. Tylecote, M. D., D. P. H. 
(Viet.), F. R. C. P. (London), and George 
Fletcher, M. A., M. D. (Glas.), M. R. C. P. 
(London), D. P. H. (Camb.) London, Ox- 
ford University Press. 1927. pp. 270. 

A concise, clear and readable guide to the diag- 
nosis and treatment of the commoner diseases of 
the lungs. The authors ride no hobbies; equally 
it is true they present no new views. Because of 
its size the book can hardly stretch beyond the 
scope of a compend. It must, therefore, share 
the defects and the advantages of brevity, ex- 
hibiting at times inadequacy of development of 
the subject but always giving a clear cut and 
easily comprehended as well as dependable picture. 

I. I. Lemann, M. D. 


Filterable Viruses: Edited by Thomas M. Rivers, 
M. D. Baltimore, The Williams and Wilkins 
Company. 1928. pp. 428. 

Dr. Rivers writes the introductory chapter cov- 
ering the general aspects of filterable viruses. He 
indicates that the ability to pass filters is a char- 
acteristic that has been greatly over emphasized 
and probably occupies too prominent a position in 
the minds of medical men. There are other char- 
acteristics of filterable viruses which appear to be 
much more important. He stresses the intimate 
relationship between the virus and the cells of the 
host and the lasting immunity they produce. He 
doubts whether they ever have been successfully 
cultivated in the absence of living host cells. 
He presents an extremely long list of diseases of 
man, other mammals, fowl, fish, insects, and 
plants for which there is evidence that they are 
due to filterable viruses. He feels sure that many 
of these are true bacterial diseases and soon will 
be dropped from the list. The chapter is ex- 
tremely brief, b^It is indeed stimulating and should 
be read by all medical men and, in fact, by all 
interested in the biological sciences. 

Dr. Mudd’s chapter on filters and filtration is 
a welcome addition to literature. I know of no 
other one place where such authoritative infor- 
mation on the scientific principles and practical 
technique of filtei-s and filtration may be obtained. 
It is regrettable that Dr. Mudd has given so little 
attention to the asbestos type of filters. 

In ten pages of fascinating reading Dr. Carrel 
gives a glimpse into the study of filterable viruses 
by the use of tissue cultures. He does not make 
the mistake that so many reviewers do of omitting 
essential details of technique. 

Dr. Cowdry in his chapter on intracellular path- 
ology in virus diseases covers such a large num- 
ber of disease entities in so brief a discussion 
that were it not for the excellent illustrations, 
the chapter would be of little value. The cell in- 
clusions he describes are one of the distinguishing 


characteristics of virus infections, as emphasized 
by Rivers in the introductory chapter. 

Dr. Amoss writes the chapter on poliomyelitis 
exemplifying filterable virus infections of man. 
Most of the data is available in his article on 
poliomyelitis in Tice’s System of Medicine. This 
article will provide little comfort for the advo- 
cates of the streptococcus theory of the etiology 
of the disease. 

Foot and mouth disease and vesicular stomati- 
tis are discussed by Dr. Olitsky. The virus of the 
foot and mouth disease is one of the most thor- 
oughly studied of all the viruses, and this chapter 
may be read by any one who wishes to know the 
complete story, as far as is now available, con- 
cerning a single virus and the disease which it 
causes. 

Dr. Goodpasture’s chapter on fowl-pox of 
chickens and pigeons. Dr. Glaser’s chapter on sac- 
brood of honey bees and the polyhedral diseases 
of insects, and Dr. Kunkel’s chapter on virus dis- 
eases of plants are of interest chiefly to the 
experimental pathologist or general biologist. 

Dr. Bronfenbrenner writes the final chapter on 
bacteriophagy. He is a critical worker in this 
field and does not commit himself to d’Herell’s 
theory that the lytic agent is a true filterable 
virus. He gives in thirty pages the essential data 
concerning the so-called bacteriophage. Reviews 
of the Twort-d’Herell phenomenon are getting to 
be fashionable. For the physician with an active 
interest in bacteriology, who has been more or 
less confused during the past few years by the 
multiplicity of articles and opinions that have ap- 
peared concerning this phenomenon. Dr. Bronfen- 
brenner’s article will be very welcome. 

Concerning the book as a whole one must be 
most enthusiastic about the bibliographies. Every 
chapter has its own and is very extensive. Dr. 
Rivers’ chapter of twenty-three pages is followed 
by a bibliography of five hundred thirty-nine 
titles, which are classified so as to make them 
readily usable. The other authors have omitted 
little that could be desired in the way of refer- 
ences. Different chapters in the book will be 
read by workers in many different fields, but only 
a few will care to read the entire book. It seems 
unfortunate that the book should cost as much as 
it does. 

R. H. Turner, M. D. 


Physical Diagnosis : By W. D. Rose, M. D. 5th 
ed. St, Louis, C. V. Mosby Co. Ulus. pi. 
1927. pp. 819. $10.00. 

In this fifth edition minor changes and altera- 
tions of no particular note have been made. The 
author has incorporated several advances in 
physical diagnosis into this new volume. The 
volume is large and contains a great deal of in- 
formation that is readily obtained. 

I. L. Robbins, M. D. 


Book Reviews 


85 


Special Cytology: Edited by Edmund V. Cowdry. 
New York, Paul B. Hoeber Inc. 1928. Two 
volumes. pp. xxi + 1348, 693 illustrations. 

The present publication forms a natural sup- 
plement to a volume entitled General Cytology, 
published in 1924 under the same editorship. The 
material included in General Cytology embraces 
the fundamentals of structure and function which 
are common to cells generally. Special Cytology 
has for its purpose a more specific treatment of 
particular cellular varieties, tissues and organs. 
The title is hardly sufticiently suggestive of the 
actual scope of the subjects included, which might 
be more aptly termed collectively “Special Cytol- 
ogy and Histology.” 

Following an introduction by Carrel, there are 
thirty-six sections, of which the topics and con- 
tributors are as follows; Skin and its deriva- 
tives, Cowdry; mucous membrane of the nasal 
cavity and paranasal sinuses, Schaeffer; epithe- 
lium of the lower respiratory tract. Miller; sali- 
vary glands, Stormont; gastric glands, Bensley; 
intestinal epithelium, C. C. and M. T. Macklin; 
cytology of the liver and its functional signifi- 
cance, Mann; cytology of the pancreas, Opie; the 
erythrocyte, Krumbhaar; lymphocytes and plasma 
cells. Maximow; the myeloblast, Downey; granu- 
lar leucocytes. Bunting; macrophages (histiocy- 
tes), Maximow; hypophysis, Bailey; pineal body, 
Tilney; thyroid, parathyroids and thymus. Marine; 
suprarenal, Stewart; renal tubules, Huber; car- 
tilage and bone, iShipley; synovial membrane of 
joints and bursae. Key; striated and smooth 
muscle, Meigs; cardiac muscle, A. E. Cohn; spec- 
ialized systems of the heart, Todd; visual cells 
and retinal pigment, Arey; cytology of the inter- 
nal ear, Shambaugh; internal architecture of 
nerve cells, Cowdry; general relation of histologi- 
cal character to function in mammalian neurones, 
Malone; sympathetic nerve cells, Kuntz; neuro- 
glia and microglia, Penfield; cytology of the 
cerebrospinal pathway, Wislocki; cytology of the 
ovum, ovary and fallopian tube. Corner; cellular 
changes in the fluid of the mammalian vagina, 
Stockard; cytology of the mammary gland, Leo 
Loeb; interstitial cells of the testis, Rasmussen; 
male germ cells, Metz ; seminal vesicles, prostate 
and bulbo-urethral glands, C. C. Macklin. 

The individual contributors deal, naturally, with 
topics in the fields of their own researches. As 
is to be expected in a co-operative enterprise, the 
various sections are not treated in a uniform 
manner. Some sections are of the usual nature 
of reviews. Others introduce, in addition, per- 
sonal evaluation of the material reviewed. Each 
section carries an adequate bibliography. 

Special Cytology should be a useful reference 
not only for workers in the biological and basic 
medical sciences, but also for clinical investigators. 

Harold Cummins, Ph. D. 


Lobar Pneumonia: A Roentgenological Study: 

By L. R. Sante, M. D., F. A. C. R., F. A. C. P. 
New York, Paul B. Hoeber, Inc. Ulus. 1928. 
pp. 137. $3.00. 

This little book of 126 pages, profusely illus- 
trated, will be of interest to any physician 
interested in lobar pneumonia as well as all 
roentgenologists. While it is primarily an roent- 
gen-ray study of pneumonia and its differentiation 
from other lung conditions, the author has at- 
tempted very successfully, to correlate the radio- 
logical findings with the known facts, clinical, 
pathological, and expei-imental. Mason and other 
investigators have shown that in children, con- 
solidation of the lungs starts in the eveoli at the 
periphery and spreads to the hilum. The author 
has demonstrated that, while this is the type most 
frequently encountered in children, it was rarely 
the type of involvement met in adults. His serial 
roentgenographic observations in adults shows 
that lobar pneumonia begins as a consolidation in 
the hilum region and spreads rapidly toward the 
periphery. These observations are in accord with 
the most recent bacteriological and pathological 
studies of the disease. The book emphasizes the 
great value of radiological studies of pulmonary 
conditions without minimizing the importance of 
careful history taking and physical examination. 
The reviewer has no hesitancy in recommending 
this little volume to the profession. 

Randolph Lyons, M. D. 


The Use of Symptoms in the Diagonsis of Dis- 
ease : By Hobart A. Hare, B. Sc., M. D., 

L.L. D. 9th ed., rev. Philadelphia, Lea & 
Febiger. 1928. PI. illus. pp. 528. 

This volume is a ninth edition. It has been 
thoroughly revised and brought up to date. It is 
a purely clinical work and all laboratory refer- 
ences have been necessarily omitted. The purpose 
of the book is to acquaint the student and physi- 
cian with the art and science and medicine and 
to re-establish it in its proper sphere of prime 
importance to the doctor and not secondary to 
laboratory procedures as is now so much the prac- 
tice. The plan is to name the different signs and 
symptoms of different portions of the body and 
the differential diagnosis to be obtained from 
them. The book is a most useful guide and aid. 

I. L. Robbins, M. D, 


Post-Mortem Appearances: By Joan M. Ross, 

M. D., B. S. (Lond.), M. R. C. S., L. R. C. P., 
with preface by E. H. Kettle, M. D. 2nd 
ed. London, Humphrey Milford, Oxford Uni- 
versity Press. 1928. pp. 225. 

A thorough revision of an extremely practical 
little book of somewhat over two hundred pages 
describing the gross appearance of the important 
organs of those who die from various types of 
disease. H. Musser, M. D. 


86 


Book Reviews 


The Principles and Practice of Obstetrics: By 

Joseph B. DeLee, A. M., M. D. 5th ed., thor- 
oug-hly revised. Philadelphia and London, 
W. B. Saunders Co. 1928. pp. 1140. $12.00. 

That a book of the size and consequent cost of 
DeLee’s Principles and Practice of Obstetrics 
should within the space of fifteen years have 
reached its fifth edition and its thirteenth print- 
ing is a surer tribute to its real merit than the 
eulogies of any reviewer. And this fifth edition 
is quite as worthy of praise as any of the pre- 
ceding volumes. 

For one thing, the physical difficulties of read- 
ing it are not quite so great because, by a slight 
change in the format, the unwieldy size has been 
somewhat reduced. There is still, however, room 
for decided improvement in. this regard. Whether 
the subject matter could be profitably abbreviated 
is a question which probably demands a negative 
answer, but frequently the reproach of verbosity 
can be justly brought against the author, and it 
might be well at some future time for a revision 
to be made simply from this standpoint. The 
book is too valuable to be condemned, as it un- 
fortunately has been, on the basis of its mere 
bulk. 

Practically the same plan has been adhered to 
as in the earlier editions, the subject being di- 
vided into the physiology of pregnancy, labor and 
puerperium, the pathology of the same, and opera- 
tive obstetrics, each with its detailed subdivisions. 
The arrangement of the subject matter visually, 
i. e., in large and small type, according to the 
relative importance of the questions under discus- 
sion, is an excellent if mechanical device, though 
naturally one does not always agree with the 
author as to what is important and what is not. 
The table setting forth the various types of 
toxemia is another excellent mechanical presenta- 
tion, as is the table dealing with the management 
of contracted pelves. The actual mechanism of 
labor has always been a particularly well handled 
subject, and the care of the breasts and the treat- 
ment of the newborn child are both handled with 
a detail foreign to the average text on obstetrics. 
The illustrations add materially to the value of 
the book, and many additions have been made to 
them. 

In every respect the subject matter has been 
brought up to date. All the important recent 
investigations in biochemistry and other labora- 
tory sciences are included, and many chapters 
have been partially or entirely rewritten, notably 
those dealing with the treatment of hyperemesis 
gravidarum, eclampsia and the other toxemias of 
pregnancy, abruptio placentae, placenta previa, 
postpartum hemorrhage, puerperal infection and 
similar conditions. Likewise the chapters dealing 
with the various operative procedures have been 


thoroughly revised. The low or cervical Cesarean 
section, which DeLee himself has done so much 
to popularize, is treated in much more detail than 
in the last edition, and the figures from the 
Chicago Lying In Hospital, six hundred twenty 
cases with only six deaths, are the author’s justi- 
fication for his advocacy of this particular pro- 
cedure. Zarate’s modified symphysiotomy is added, 
as is the Gottschalk-Portes exteriorization of the 
uterus after Cesarean section in infected cases. 
The author’s comment is that if the claims of the 
latter procedure can be substantiated, as they ap- 
parently can be, the whole chapter of the manage- 
ment of infected labors must be rewritten, and the 
field of the Porro operation and of craniotomy on 
the living child can be very materially reduced. 

The radicalism of this author is always a favor- 
ite topic with reviewers and in some respects, at 
least, the approach is justified. Even the fact that 
he would limit certain procedures to the expert 
obstetrician operating in the well equipped mater- 
nity does not, it seems to me, lessen the danger 
of advocating such methods as cervical manipula- 
tions in uterine inertia (p. 615), the manual re- 
moval of retained placental fragments except on 
very strictly limited indications (p. 833), and the 
application of the vulsellum to steady the fetal 
head after manipulation in face presentations 
(p. 995). Against this, however, must be set his 
conservatism in the management of puerperal in- 
fection and particularly infected abortions, in the 
management of placenta previa, in the use of 
pituitrin, in the repair of cervical lacerations after 
delivery, and in a hundred similar instances. In 
my own opinion, the radicalism of DeLee has be- 
come a tradition with certain reviewers, and I am 
inclined to believe that most often it is more 
apparent than real. 

Certainly, as the author points out, the con- 
tinued high mortality in obstetrics is a justifica- 
tion for his view that pregnancy and labor are 
largely pathologic, and his insistence on the essen- 
tially surgical nature of this division of medicine 
is not ill-advised in a day when the general feel- 
ing seems to be that no special qualifications are 
required to handle a delivery other than the right 
to add M. D. to one’s name. 

This is rather too full a text to put into the 
hands of the average medical student for his daily 
use but it is an invaluable book of reference, a 
real encyclopedia, both for the general practi- 
tioner who does obstetrics and for the obstetric 
specialist who endeavors to keep abreast of the 
times. It is one of the few books in any tongue 
in which obstetrics is presented both as a science 
and as an art, and in which the subject receives 
a really dignified and adequate presentation. 

C. Jeff Miller, M. D. 


Book Reviews 


87 


An Outline Histwy of Ophthalmology: By T. H. 

Shastid, A. M., M. D., F. A. C. S., Sc. D., LI. 

B. Southbridge, Mass., American Optical Co. 

1927. pp. 33. 

If you really love Ophthalmology, read this 
small volume. You xvill enjoy every word. It 
will bring before your eyes the procession of 
ophthalmic progress from the days of Ancient 
Babylon to our generation and will enable you to 
shake hands with Hippocrates and chat with von 
Graefe. 

Hippocrates will tell you how he treated 
trachoma some twenty-five hundred years ago 
with conjunctival massage in pretty much the 
same way that we use today. 

Some two thousand years ago a Roman named 
Celsus elaborated on the then existing Coljnria. He 
tried everything from camel dung to cod-liver oil, 
with and without religious ceremonies of various 
sorts. He at least knew that oily substances pro- 
tect the cornea when its surface was abraded. 

Although the word cataract was uot used until 
a later date, lens opacities were considered due to 
an opaque fluid which flowed downward between 
the pupil and the lens, by Rhazas, an Arabian who 
lived about a thousand years ago. He also noted 
that the pupils become smaller when exposed to 
light. Alhazen a fellow country-man somewhat 
later worked out the fundamentals which under- 
lie modern optics. He was the first to understand 
that vision is produced primarily by the light 
which comes from the object at which we look. 

As the result of an accident in the course of a 
cataract depression in 1745, large fragments of 
lens fell into the anterior chamber, which Daviel 
removed by means of a scissors incision in the 
cornea — the first cataract extraction. 

Although Von Helmholtz in 1850 discovered that 
the back of the eye could be examined with the 
'optholomscope, the real discoverer was an Eng- 
lishman named Charles Babbage, who through an 
unfortunate chain of circumstances, did not re- 
ceive the credit nor recognition of his efforts. 

These are but a few of the interesting facts that 
the author tells us. 

It is with great regrest that we read that Dr. 
Shastid will retire from opthalmic literature. 
For practically a generation he has devoted his 
time, efforts, and exceeding literary ability largely 
to recounting the lives of those who have made 
opthamology. Practically, unassisted he wrote 
the biographies in the American Encyclopedia of 
Ophthalmology. Without his efforts our specialty 
would be poorer and most of us would not be near- 
ly so well acquainted with those who have conse- 
crated their lives to helping the world see better. 

Chakles a. Bahn, M. D. 


Healthy Growth: By Alfred A. Mumford, M. D. 

London, Oxford University Press. 1927. pp. 

384. 

The author of this excellent book desires to at- 
tack the problem of healthy growth from a dif- 
ferent angle from previous methods. The author 
has in mind the adolescent schoolboy, whom he 
feels has not been properly equipped for the great 
perplexities of later life. He attributes this fail- 
ure to our possesion of inadequate standards of 
healthy growth, both from the physical and 
mental standpoint. 

Throughout the book the author endeavors to 
substantiate his arguments by many elaborate 
experiments and complicated charts of what he 
thinks are standards. It is the reviewer’s opinion 
that much of this could be condensed. However, 
anyone desiring exhaustive information along 
lines of physical and mental development is 
recommended to read this book, as it is un- 
doubtedly written in a most delightful style. 

O. M. Larrimore, M. D. 


Troubles We Don’t Talk About: By J. F. Monta- 

gue, M. D., F. A. C. S. Philadelphia, J. B. 
Lippincott Company. 1927. pp. 248. 

A book for the laity written by a proctologist 
of broad mind and keen intelligence. 

J. H. Musser, M. D. 


The Prevention of Preventable Orthopedic Defects: 
By S. C. Woldenberg, B. Sc., M. D., M. Sec. St. 
Paul, Bence Publishing Co. 1927. pp. 120. 

This is the first time your reviewer has ever 
seen a book which has attempted to deal with pre- 
ventable surgery, and as our good friend Dr. Rid- 
lon in his foreword says: “When the author 

asked me for advice, I harbored a secret hope that 
he might to some extent point out the way to elim- 
inate much of the present surgery from Ortho- 
pedic surgery”. 

The book does not attempt anything new and as 
is covers a large field in 120 pages, little can be 
said on any one subject. However, there are 
many valuable suggestions brought out and a pe- 
rusal of the book is well worth one’s time. 

Edward S. Hatch, M. D. 


Annals of the Pickett-Thomson Research Labora- 
tory, Volume II. Baltimore, Williams and 
Wilkins Company. 1927. pp. 316. 

A large paper-covered tome devoted to research 
on streptococci, with extensive bibliography and 
many very excellent plates. 

J. H. Musser, M. D. 


88 


Book Reviews 


The Examination of Patients: By Nellis B. Fos- 

ter, M. D. 2nd ed., rev. Philadelphia, W. B. 
Saunders Company. 1928. pp. 392. 

There is a great tendency in medical teaching 
to do away with much of the former old methods 
of instruction, such as those, for example, which 
require men studying for medicine to learn an 
enormous amount of material by rote and without 
thought. The present book by Foster exemplifies 
very well indeed this method of teaching. The 
important, salient features in the examination of 
the patient are disclosed and are presented in a 
real and attractive manner. There is no attempt 
to list a thousand and one different signs and 
symptoms which every practitioner of medicine 
who has been out more than a few years has 
forgotten and which do not form the basis of that 
man’s knowledge of clinical medicine. It is for 
this reason that the book is of value. It stresses 
the important and does away with a tremendous 
amount of the unnecessary and trivial. 

J. H. Musser, M. D. 


Ophthalmic Year Book: V. 23. 1927. Chicago, 

Ophthalmic Pub. Co. 1927. pp. 338. 

This review of literature will probably be the 
last of a valuable collection of digest and bibli- 
ography, for the reason that it lacks volunteer 
literary help and financial backing. This is un- 
fortunate for it has been greatly appreciated by 
many, yet great numbers have neglected to give 
to it actual support. Let us hope that this will 
not be the case and that it will be possible to 
continue the publication as heretofore. 

T. J. Dimitry, M. D. 


A Text-Book of General Bacteriology : By Edwin 
O. Jordan, Ph. D. Ulus. 9th ed., rev. Phil- 
adelphia, W. B. Saunders Company. 1928. 
pp. 778. 

The ninth edition of this standard text-book on 
bacteriology needs no introduction to the world 
of bacteriologists nor does it need much acclaim- 
ing to the medical profession as a whole, many 
of whom have learned from its pages much that 
they know about bacteriology This new edition 
has been added to and amended as well as deleted 
in part, for its presents size is much the same 
as previous editions. Dr. Jordan has revised and 
rewritten the chapter on parasitic protozoa, he 
has added new material on the bacteriology of 
scarlet fever, erysipelas and rheumatic fever, and 
the section on bacteriology of water has been ex- 
tensively altered. Minor changes have been made 
so as to bring the subject matter thoroughly up 
to date. 


PUBLICATIONS RECEIVED. 

F. A. Davis Company, Philadelphia; Hay- 
Fever and Asthma, by Ray M. Balyeat, M. A., 
M. D., F. A. C. P. 

Williams & Wilkins Company, Baltimore: 
Nutrition, by Walter H. Eddy, Ph. D. 

P. Blakiston s Son & Co., Philadelphia: Prac- 

tical Cliincal Psychiatry for Students and Practi- 
tioners, by Edward A. Strecker, A. M., M. D., 
and Franklin G. Ebaugh, A. B., M. D. 

C. V. Mosby Company, iSt. Louis: Operative 

Surgery, by J. Shelton Horsley, M. D., F. A. C. S. 
Modern Methods of Treatment, by Logan Clen- 
dening, M. D. Clinical Gynecology and Obstetrics, 
by Rae Thornton La Vake, A. B., M. D., F. A, C. S. 
Syphilis, by Henry H. Hazen, A. M., M. D. The 
Duodenum, by Pierre Duval, Jean Charles Roux 
and Henri Beclere, translated by E. P. Quain, 
M. D. 

W. B. Saunders Company, Philadelphia and 
London: Collected Papers of the Mayo Clinic 

and the Mayo Foundation. Clinical Medicine, by 
Oscar W. Bethea, M. D., Ph. G., F. C. S., F.A.C.P. 
Addresses on Surgical Subjects, by Sir Berkeley 
Moynihan, Bart, Gynecology, by William P. 
Graves, A. B., M. D., F.A.C.S. 

The MacMillan Company, New York: Folk- 

lore of the Teeth, by Leo Kanner, M. D. 

William Wood and Company, New York: In- 

ternational Medical Annual, 1928. 

Gaston Doin et Cie, Paris: Les Associations 

Microbiennes Leurs Applications Therapeutiques, 
par G. Papacostas & J. Gate. 

Rockefeller Foundation, New York: Methods 

and Problems of Medical Education. 

Nervous and Mental Disease Publishing Co., 
New York and Washington: Introduction to the 

Technic of Child Analysis, by Anna Freud of 
Vienna. 

Gaston Doin & Cie, Paris; Precis de Medicine 
Infantile. 

Nurses, Patients, and Pocketbooks, report of a 
study of the economics of nursing conducted by 
the Committee on the Grading of Nursing Schools, 
by May Ayres Burgess, Director. 

Reprints. 

Report of Committee appointed to Investigate 
Definition of Terms used in active Optic Path- 
ology. The Treatment of Malarial Anemia, by 
Joaquin R. Toba, M. D. Gonorrhea in Women: 
Its Treatment by Diathermy, by Winfield Scott 
Pugh, B. S., M. D. 


J. H. Musser, M. D. 


New Orleans Medical 

and 

Surgical Journal 

Vol. 81 AUGUST, 1928 


YESTERDAY AND TODAY IN 
MEDICINE.* 

J. AUGUSTUS CRISLER, M. D., 
Memphis, Tenn. 

Approaching an age in medical life in 
which I am privileged to look back over 
the years that have gone, I stand now 
with cherished thoughts of the romance of 
medicine of yesterday and with proud 
recognition of the achievement of medical 
science of today. 

In contemplation of the future, I feel the 
thrill which should be felt in the heart of 
every young medical man as he begins his 
career, trained as a scientist by modern 
educational methods, and inspired as an 
idealist by the noble example and precept 
of those whose memory we delight to 
honor. 

More than thirty years ago, when I be- 
gan the practice of medicine, the leaders 
of our profession in Mississippi were not 
specialists or research laboratory workers, 
but general practitioners — clinicians of 
culture as well as of learning. They ac- 
complished much with simple equipment, 
and arrived at their diagnosis without the 
aid of laboratory refinements, and made 
their visits without the dispatch and com- 
fort of motor cars traveling over hard sur- 
faced roads. Without instruments of pre- 
cision they developed ingenuity and re- 
sourcefulness, and without intense scien- 
tific training they displayed a compensa- 

* Oration in Medicine, Mississippi State Medical 
Association, Meridian, May 10-12, 1928. 


No. 2 

tory clinical acumen akin to a sixth sense, 
or tactus eniditm. They knew their pa- 
tients through personal contact and asso- 
ciation, and they studied the experiments 
which nature made upon the sick and the 
suffering. Through long hours of patient 
watchfulness and attendance, they studied 
the natural phenomena of disease, and 
learned to assess correctly the value of 
symptoms. Their reputations were rather 
local, but they stood high in the profession 
of this State, and were held in the highest 
esteem by the people of their communities. 
Their contributions were more to the alle- 
viation of suffering through their daily 
work than to the store of scientific knowl- 
edge. 

Such pioneers as Ward of Winona, Isom 
of Oxford, Taylor of Corinth, Minor of 
Macon, Vaughan of Meridian, Jones and 
Bennett of Brookhaven, Wert Johnson of 
Jackson, Quinn of Vicksburg, Dunn of 
Greenville, Young and Sharp of Grenada, 
and many others exhibited a rare combina- 
tion of brain and heart which molds char- 
acter, and left to this society a rich heri- 
tage. They were the Sydenhams and Mc- 
Kenzies of Mississippi Medicine. 

A change, however, has been wrought 
by the improvement in medical education 
and the facilities for post-graduate study, 
and what phenomenal results have fol- 
lowed the discoveries of experimental in- 
vestigation. 

Our young medical men are being more 
thoroughly and scientifically trained than 
in the earlier days when they were given 


90 


Crisler — Yesterday and Today in Medicine 


two years of lecture courses, but it seems 
to me that they fail to grasp and to hold 
as their own, the mass of scientific facts 
which is crowded into the curriculum. In 
other words, I doubt if their retentive 
powders are as good as those of the older 
men. As prophesied by Osier, some of our 
recent graduates tend to exhibit a kind of 
medical Chauvinism ; that is to regard 
lightly the thoughts and work eminating 
from any but their own alma mater, their 
devotion to which seems to prejudice them 
against the work of other, perhaps, less 
recognized institutions. By raising the 
standard of medical colleges, and con- 
stantly changing the methods of instruc- 
tion, medical education has been greatly 
improved, but its problems are still un- 
solved. The value of post-graduate study 
is well illustrated by the benefits which 
some of the men derived from their in- 
struction and experience during the World 
War, and everywhere opportunities for 
post-graduate study are increasing and are 
available to all. 

As a corollary to the education of our 
students and ourselves there is the prob- 
lem of education of the public in matters 
of health, so that they shall learn to re- 
cognize men of training and ability and 
not be misled by those who have only the 
qualities of plausibility and persuasive- 
ness. In the campaign for periodic health 
examinations, and in the dissemination of 
information about cancer and tuberculosis, 
we are trying to stress the importance of 
early recognition of disease. In order that 
the profession may not be found wanting 
in its knowledge, we must learn more of 
the early indications of disease processes, 
for after all many of our clinical symptoms 
of disease are in reality very late manifes- 
tations. For instance in the older text 
books, the diagnostic symptoms of carci- 
noma of the breast were pain, enlargement 
of the axilliary glands and a lump in the 
breast, with discharge and ulceration. As 
some one has aptly expressed it, “these are 


not signs of cancer of the breast, but the 
symptoms of death.’” 

With the introduction and increasing use 
of mechanical means of examination, much 
that was hitherto obscure, is now made ac- 
cessible, and our clinical interpretation of 
symptoms and signs find added weight in 
the visualization of actual structural 
change, or the expression of functional in- 
capacity of an organ. Through the use of 
opaque photographic media, the roentolo- 
gist now shows us the contour of the gall- 
bladder and the urinary bladder, the out- 
line of the kidney, pelvis and calyces, the 
structural integrity of the duodenal bulb, 
the size, shape and general outline of 
the maxillary sinuses, the distribution of 
the bronchial tree, the outline of the 
uterus and tubes, and even the ventricles 
of the brain may be photographed. One 
may well speculate on the future diagnos- 
tic possibility of the roentgen-ray in medi- 
cine. 

Hitherto used only in larger hospitals 
and laboratories devoted to experimental 
study, the electrocardiograph is now rapidly 
coming into general use, and we daily in- 
terpret the written record of the irregu- 
larities of the heart beat and with accuracy 
and certainty locate disturbances in the 
conducting bundle of His. 

The metabolimeter expressing the rate 
of metabolic activity has proven of unques- 
tionable value in detecting the disturb- 
ances of the thyroid gland. No longer is 
the diagnosis of myxedema confined to 
those well defined cases manifesting dry 
skin, course hair, heavy features, brittle 
finger nails and rapidly increasing weight, 
but we have come to recognize the early 
case of hypothyroidism, and have learned 
to combat the disease in its earliest mani- 
festations. 

Along with this development of mechani- 
cal aids in medicine has gone the brilliant 
study and progress of biochemistry and 
physiology. The suspected nephritic is 
investigated by an estimation of the func- 


Crisler — Yesterdfiy and Today in Medicine 


91 


tional capacity of the kidneys, by the de- 
termination of the degree of nitrogenous 
retention in the blood, the variation in 
specific gravity of several specimens of 
urine, and the ability of the kidneys to ex- 
crete a selected dye. 

Disturbance of the acid-alkali equilib- 
rium of the blood are now detected through 
studies of blood chemistry, and from this 
knowledge has come an interpretation of 
previously little understood symptoms, and 
the development of methods for combating 
and preventing such imbalances as alkalo- 
sis and acidosis. The estimation of the 
chloride content of the blood is of particu- 
lar value in establishing the presence or 
absence of alkalosis, and the carbon dioxide 
combining power of the blood plasma is an 
index of the degree of acidosis. 

Recently much interest has been dis- 
played in calcium metabolism and the in- 
fluence of the parathyroid glands on the 
complete metabolic activity of calcium has 
been definitely established. The occurrence 
of tetany no longer presents a problem and 
through knowledge acquired, we have 
means of combating this disturbance of the 
physiology of the organism. Tetany fol- 
lowing thyroidectomy is easily recognized 
and immediately controlled by such specific 
therapy, as parathyroid extract and cal- 
cium. 

The comparatively recent isolation of 
the hormone insulin, which in some manner 
controls the metabolism of carbohydrates, 
thereby influencing the metabolic activity 
of fats, was perhaps the most outstanding 
medical achievement of the century. The 
period of expectancy of the adult diabetic 
has been greatly increased, and the juve- 
nile diabetic no longer drifts into malig- 
nant acidosis and coma. His growth and 
development progress normally over a 
period of years, and who knows but what 
he may be carried into productive man- 
hood and citizenship by means of this ex- 
tract from one of the glands of internal 
secretion? As a consequence of the use of 


this remarkable agent, we no longer fear 
the results of major surgical procedures in 
those individuals, manifesting the clinical 
syndrome of glycosuria, hyperglycemia 
and acidosis. 

We are learning more of chemical, bio- 
logic, and physiologic pathology instead of 
contenting ourselves with the knowledge of 
structural changes. We are not satisfied 
to know that a patient has a heart mur- 
mur, but we must try to determine the 
functional capacity of this organ. For 
after all symptoms are manifestations of 
disturbed function, and not of structural 
changes, and many of our newer methpds 
of investigation are attempts to estimate 
the functional capacity of various organs. 
For instance, the method of cholecysto- 
graphy, originated by Graham, is an at- 
tempt to demonstrate the ability of the 
gall-bladder to concentrate and to empty, 
which are its only established functions. 

With renewed interest and remarkable 
originality of thought, the best minds of 
today are centered upon the physiological 
interpretation of the function of the liver, 
whjch is) unquestionably the biochemical 
laboratory of the human body. Is it too 
much to prophesy that from these studies 
hitherto unexplained physiopathological 
reactions will not only be correctly inter- 
preted, but means and measures for their 
prevention and cure will be provided? 
Crile says “Life depends upon the liver.” 

More and more we are learning to re- 
cognize the expression of the sympathetic 
autonomic nervous system in the produc- 
tion of symptoms. Long overlooked, its 
influence on visceral activity is beginning 
to be recognized, and with an increasing 
knowledge of physiology we are learning 
to appreciate how disturbances of the syint- 
pathetic nervous system can materially in- 
fluence the viscera in hastening and main- 
taining their evident departures from nor- 
mal. Such operations as periarterial sym- 
pathectomy, denervation of the stomach, 
and cervical sympathectomy are impres- 


92 


Crisler — Yesterday and Today in Medicine 


sive examples of the efforts of surgeons to 
treat disease manifestations by correcting 
hyperphysiological activity of the nerves 
supplying a viscera. 

Another advancement in the treatment 
of disease is in limiting our use of reme- 
dies to those natural agents : diet, sunshine, 
fresh air, and rest, and to those few well 
tried drugs whose pharmacological value 
has been thoroughly established. But we 
must be cautious lest the avalanche of 
pseudo-scientific literature which covers 
our desks leads us back to the use of a 
score or more of remedies for every symp- 
tom. 

Many diseases are fairly well treated in 
the individual without having as yet dis- 
covered their etiology. Pernicious anemia 
seems to be greatly improved by feeding 
whole liver and liver fraction. However, 
the problem of preventive treatment of 
these diseases is inadequately met until 
their causes are established. When etio- 
logical agents are discovered the medical 
profession is quick to turn this knowledge 
into the path of prevention. We have 
stamped out smallpox, yellow fever, bu- 
bonic plague, and epidemics of scarlet 
fever and typhoid fever are becoming less 
severe. Witness the control of malaria and 
typhoid fever in your own dear State. 

Perhaps no other disease has received as 
much scientific investigation as cancer, yet 
despite the ceaseless co-operative efforts 
of the labo ra to ry-- worker, the clinician and 
the surgeon, the cause of cancer still re- 
mains hidden in apparently hopeless ob- 
scurity. In our eternal hope we have in- 
vestigated the cures employed by quacks, 
and have accepted with enthusiasm the 
scientific suggestions of research workers, 
only to find in the end disappointment and 
failure. For the cancer patient we use 
surgery, radium and roentgen-ray, but for 
the control of cancer we are dependent 
upon educating the public to the import- 
ance of early treatment, and to the recog- 
nition of precancerous lesions. 


The ever widening field of medicine of 
today has developed the specialist, a man 
who, by limiting his scope of activity, is 
able to acquire more accurate and exten- 
sive knowledge in his particular branch of 
the science. There are those who claim to 
be specialists who have no more diagnostic 
skill nor successful methods of treatment 
than the old family doctor. Other special- 
ists become mere technicians, having lost 
sight of disease a,s it effects the entire 
organism and find explanation of every 
symptom in the disturbance of the organs 
they treat. McGuire says: “His patients 
often suffer from special attention and 
general neglect. Motes are pulled out of 
the eyes and beans are left in the belly, 
or the abdomen is invaded for real or sup- 
posed appendicitis and the lungs are left 
to fight their own battle with tuberculo- 
sis.” 

To offset the disadvantages of specializa- 
tion, there is the system of group medicine, 
a kind of medical teamwork which func- 
tions as the surgical team does in the oper-. 
ating amphitheatre. But above all, we 
need today, as we have always needed, the 
competent general practitioner, for he is 
the backbone of medicine, and the stand- 
ard by which our progress is measured. 

And he it is I would applaud — this gal- 
lant crusader; this tireless minister to the 
poor; this fearless counsellor of the rich; 
this faithful friend to the unfortunate ; this 
zealous and undaunted seeker after truth. 

It is the glow of his steadfast, if some- 
times feeble torch, that has lighted the in- 
candescent way to thrilling discoveries in 
the laboratories of today. It is the sturdy 
tread of his untiring footsteps that echoes 
down the corridors of science. It is from 
his hand that the young doctor of todoy 
will receive the scroll as did the runners 
in the ancient days. It is from his lips 
they will hear the words of courage: “Go 
on — Go on ; my body is weary, but my 
spirit travels with you.” 


Miller — The Young Physicixm 


93 


THE YOUNG PHYSICIAN.* 

C. JEFF MILLER, M. D., 

New Orleans. 

All valedictory and baccalaureate re- 
marks have certain handicaps to overcome, 
and the Ivy Day address is in even worse 
case than any of the others. Besides being 
delivered on a particularly hot morning in 
June, it is always made by a member of 
the Medical Faculty, from the voices of 
whom, after years of dutiful listening, the 
graduates might expect at this time to 
have surcease. I feel for you, gentlemen, 
and I shall show my sympathy in a prac- 
tical way by being as brief as I can. 

The traditional observation that com- 
mencement is truly the beginning of active 
life is not quite exact in regard to the 
medical graduate. Most of you — I wish it 
could be all of you — will serve one or more 
interne years, and during them, I venture 
to predict, you will learn more of your 
profession than you have learned in all 
your college classes. It is not the rule 
here, as it is in certain other schools, that 
the medical degree is withheld until a 
year’s interneship has been completed, and 
I am not sure that this is the wisest way 
to accomplish the result, but certainly the 
principle is absolutely correct, ' that no 
man is fitted to practice medicine inde- 
pendently until he has practiced it on ac- 
tual patients and under strict supervision. 

The great weakness of medical education 
today is, as you know, that the contact 
with patients during the undergraduate 
years is extremely brief. The laboratory 
or pure sciences are in the saddle, and, as 
more than one voice of authority has pro- 
claimed, we are in danger of forgetting 
that the function of the medical school is, 
after all, to train physicians to minister to 
the sick. More and more in the last quar- 
ter of a century has the clinical aspect of 
medicine been slighted in medical educa- 
tion. The heads of departments in the 

*Ivy Day address, Tulane University School of 
Medicine, June 12, 1928. 


foremost schools of the country are no 
longer active clinicians. They are full- 
time men, well trained, able, scholarly, I 
grant you, but nevertheless men whose 
point of view is warped by the fact that 
they have no real contact with patients, 
that their activities are largely or entirely 
confined to the classroom and to the lab- 
oratory. I do not propose on an already 
warm morning to enter upon the vexed 
discussion of laboratory versus clinical 
medicine, which would make us all much 
warmer than we are now. But I would 
point out that most of the verbiage could 
be eliminated from the argument if com- 
mon sense were permitted to rule the 
situation, if it were realized that the one 
aspect of medicine is the complement of 
the other, and that neither the clinician 
nor the laboratory worker can live to him- 
self alone. The practising physician is 
bound to the research physician by a thou- 
sand indissoluble ties, and, as Cushing 
aptly says, it could not possibly harm a 
teacher of the preclinical sciences to have 
served a house-officership, nor could it 
dampen his investigative ardor to spend 
an occasional hour or two in contact with 
patients in the wards or the clinics. 

Whether the old system of medical 
education, which put most of the empha- 
sis on the clinical side, produced better 
physicians than the present system, in 
which the emphasis is reversed, is the acid 
test of the problem, and you of this medi- 
cal generation will write the answer in 
your own achievements. Personally, I was 
educated under the old system and I have 
always regretted that my laboratory train- 
ing was so slight. But I fear that we are 
going too far in the other direction, and I 
know that Graves is right when he says 
that the modem medical graduate has had 
little training in practical therapeutics and 
none at all in the humanities of medicine. 
And because this is so, I know that an in- 
terne year, a practical apprenticeship, as it 
were, is infinitely more necessary and more 
desirable now than it was twenty-five years 
ago. 


94 


Miller — The Young Physician 


After the interne year, what? Well, 
another over-worked tendency in medicine 
today is too early specialization. Some de- 
gree of specialization, of course, is inevit- 
able, for the march of medical events has 
been too rapid to permit the individual phy- 
sician any longer to be all things to all 
patients. But let me remind you that all 
successful specialism is built upon the foun- 
dation of general practice. You cannot 
treat special diseases until you realize their 
relation to general diseases, until, as Ches- 
terton puts it, you see “the broad daylight 
of proportion which is the principle of all 
reality”. 

And if you prefer general practice, if 
you have no leaning toward any of the 
specialties, by all means remain in general 
practice. We need more general practi- 
tioners today, as a long-suffering and 
loudly-complaining public will testify. 
There is no stigma of disgrace, no hint of 
contumely, attached to these men of fine 
devotion and consecration whose feet are 
set, if you will, in the middle ways. The 
profession of medicine needs few things 
more than a recrudescence of the old-fash- 
ioned family physician. 

But if you do decide to specialize, you 
must realize at the outset that something 
more is needed than the mere decision to 
do so. Special practice implies special 
training. I take surgery as my illustra- 
tion because it has a constant lure for the 
young graduate, but what I have to say is 
applicable to any branch of medicine. 
Whether the day will ever come when there 
will be more restrictions on the practice of 
surgery than there are at present, I can- 
not say, but I greatly fear that unless we 
clean our own house, other duly consti- 
tuted authorities will clean it for us. No 
other branch of medicine is fuller of self- 
appointed specialists, no other branch ac- 
tually requires a more thorough prepara- 
tion. “A man,” says DaCosta, “who tries 
to start out as a surgical specialist never 
learns the rudiments of surgery through- 
out all his days,” and W. J. Mayo is not 
unduly harsh when he says that “young 


men without special training are not to be 
encouraged in wanton assaults on major 
surgical diseases unless justified by neces- 
sity,” a necessity, I might add, which sel- 
dom exists in these days of easy transpor- 
tation and many hospitals. 

Manual dexterity is the smallest part of 
the surgeon’s kit. Far more does he need 
surgical judgment and a surgical con- 
science and that most prosaic thing, a 
knowledge of surgical anatomy. Moyni- 
han, you will remember, stresses the im- 
portance of learning pathology on the liv- 
ing subject, but you will note that he does 
not include anatomy in the lesson. Do not, 
I beg of you, attempt to learn anatomy in 
the operating room and on your patients. 
The place to learn it, the only place to 
learn it, is in the dissecting room and on 
the cadaver. DaCosta says that when it 
comes to surgery some people do not know 
enough to be afraid; that knowledge, I 
fear, comes only with the years, but at 
least, if you determine to be a surgeon, 
write it on your heart that the best sur- 
geon is often the man who does the small- 
est amount of surgery, and that under cer- 
tain circumstances, at least, time may be 
the best surgeon of us all. 

No matter what branch of medicine you 
elect to follow, you must be students until 
the end of your days. Medicine does not 
stand still and of the making of its books 
there is no end. If you have not already 
cultivated the habit of study — and it is 
astonishing how many college graduates 
have not — then use your spare time — of 
which, alas, you will have much in the first 
years of your practice — to form the habit. 
If you are so exceptional and so fortunate 
as to be busy at once, then make the time. 
But read regularly, make systematic study 
an integral part of your life, lose no oppor- 
tunity of observing the work of others, at- 
tend medical meetings, visit hospitals and 
clinics, finally, when you have something 
to say, do not hesitate to say it or to write 
it yourself. “The man,” says Francis 
Bacon, “that is young in years may be old 


Miller — The Young Physician 


95 


in hoars if he have lost no time.” Turn 
the lean years to account by cultivating 
the ha nits of the student, by keeping 
abreast of the medical times, and you will 
find yourself repaid a hundred fold and 
more. 

Why you have decided to be physicians 
I do not know, and I greatly doubt whether 
many of you know either. There are some 
among you, J am sure, who have really had 
a vocation, v ':io, as wise old Stephen Paget 
says, ‘Vere railed to be doctors before 
(you) were ca.led to be babies,” but most 
of you, I am sure, are where you are for 
more accidental reasons. Some of you, I 
question not, have erred in your choice, are 
realizing, even now, that you are not where 
you would be, that your love lies elsewhere. 
If this is so, if you can honorably retire, 
do so before it is too late. But most of 
you will not be so situated as to be able to 
throw away these years of preparation, 
and you must lie upon the bed you have 
made. Remember, in that case, that in 
many lives — I had almost said in most lives 
— duty faithfully done may well take the 
place of inspiration, and that the grace of 
courage, in the phrase of the beloved and 
gallant R. L. S., is a staff which each of 
us may cut for our own journey. 

Even those of you have turned to medi- 
cine from sheer love, who follow it with 
the devotion St. Francis lavished on his 
dear Lady Poverty, have chosen a life of 
arduous toil, a life that in its very essence 
will never be an easy one. Whether you 
will it so> or not, from this time forward 
your life belongs largely to others. You 
are dealing in human lives, you are set 
above other men in that, as far as mortals 
may, you hold the issues of life and death 
in your hands. You will know anxious 
days and wakeful nights, you will know 
self-reproach and many misgivings and 
much soul-searching and heart-breaking 
care. You cannot be faithful to your pro- 
fession and avoid these things. You will 
know what it is to give without stint of 
your time, of your knowledge, of your skill, 
of your very self, and sometimes to give it 


all in vain. You have chosen a profession, 
not a trade, a profession whose only reason 
for being is to succor mankind, to add to 
the sum of health and happiness on earth, 
not to exploit human beings for personal 
gain. Your reward will be in kind quite 
as often as in coin of the realm, but no 
matter what it is, no matter if it does not 
come at all, the medical profession, like 
the priesthood from which it springs, must 
not be commercialized. “The world must 
return to the word duty and be done with 
the word reward.” 

Stevenson, in one of his letters, says that 
he went to church and the clergyman did 
his best to make him hate him. I am afraid 
I am in the situation of that clergyman. I 
have certainly preached to you, and in 
these unregenerate days it is highly un- 
fashionable to preach and equally unfash- 
ionable to listen, as you, perforce, have 
been obliged to do. I realize that I have 
said nothing to you which you do not 
already know. I have merely tried to re- 
mind you again of a side of the medical 
profession which in the busy round of col- 
lege and in the practical atmosphere of 
these modern days you are all too likely to 
forget. You are as much bound by the old 
Oath of Hippocrates as if, as is still the 
custom in some medical schools, you had 
actually subscribed to it, and you will learn, 
as the years go by, that “only in accom- 
plishing this oath and not confounding it” 
may you expect to have “enjoyment of life 
and art” and “good repute among all men 
for ever and ever.” 


Spirochetal Jaundice. — In the eighth proved case 
of Leptospira icterohemorrhagiae reported in the 
United States, the symptoms, including the usual 
relapse, were characteristic of this disease. The 
mode of infection could not be determined. Mul- 
holland and Bray state that jaundice with high 
fever, prostration, muscular pains, nosebleed or 
hemorrhage with lymphocytosis and many large 
lymphocytes should make one suspect Weil’s dis- 
ease. The diagnosis can be made in the early 
stages by inoculating a guinea-pig with the pa- 
tient’s blood. The authors agree with numerous 
other writers that mild jaundice, as seen in epi- 
demics, particularly prevalent in institutions, is 
probably not of this type, for injections of blood 
into the guinea-pig from a number of such cases 
gave entirely negative results. J.A.M.A., 90:1113, 
1928. 


96 


Garrison — The Control of Tnbercvlosis in Infants and Childreni 


THE CONTROL OF TUBERCULOSIS IN 
INFANTS AND CHILDREN* 

HARVEY F. GARRISON, M. D., 
Jackson, Miss. 

There are many factors which will 
necessarily enter into any program of pre- 
vention of tuberculosis in infants and 
children. Tuberculosis is defined by prac- 
tically all the authorities as the condition 
resulting from an invasion of the body by 
the tubercle bacillus or as a spiecific in- 
fectious disease caused by the invasion of 
the body by the tubercle bacillus. 

For a more practical working basis it 
occurs to me that we should consider the 
disease both contagious and infectious. It 
is generally accepted now that practically 
all of our tuberculosis is contracted in in- 
fancy or childhood. In many instances 
the disease is arrested and remains dor- 
mant over a period of years or until the 
invasion of the body by some other disease 
lowers the vitality and reduces the pa- 
tients resi(sting power. 

There are only two types of tuberculosis 
which we may consider of importance in 
the discussion of this subject at this time: 
the human and the bovine. We contract 
most of our tuberculosis by contact. In the 
fight against tuberculosis there has been 
a reduction ijn the number of deaths but 
not a proportionate reduction in the inci- 
dence of the disease. In other words our 
activities have been centered more on the 
cure or arrest of the disease and the pro- 
tection of the sick patient in order to pro- 
long his life rather than the prevention of 
the disease in others. 

Eugene L. Opie and Hans Anderson 
state that the lesions which occur in the 
lungs of almost all individuals who die 
from conditions other than tuberculosis 
have the characteristics of tuberculosis of 
childhood ; that is, they occur as foci of in- 
fection in the substance of the lung and are 


*Read at the Mississippi State Medical Associa- 
tion meeting, Jackson, Miss. 


not more frequent in the apices than else- 
where. Surely it is very logical to believe 
that childhood tuberculosis is the forerun- 
ner of the adult type. Then if adult tuber- 
culosis is to be successfully combated it 
should be attacked at its source, namely in 
infancy and childhood. 

There is no doubt now that the incidence 
of tuberculosis infection has been exagger- 
ated in this country, yet we know that 
around one hundred thousand people die of 
the disease in the United States every year. 
We are losing about two thousand people 
annually in Mississippi from tuberculosis 
and this does not include the many deaths 
from other causes in whom tuberculosis 
was a factor. Von Pirquet in 1909 pub- 
lished statistics from Vienna on 1334 
children* up to 14 years of age. He showed 
that 70 per cent of the children gave a 
positive tuberculin skin test and that 90 
per cent at 14 years of age reacted posi- 
tively to tuberculin. These statistics 
were adopted as universal and as a 
standard in this country, but recent data 
obtained by recognized authorities have 
proven the extent to which we have been 
mistaken. It would seem that the inci- 
dence of tuberculous infection in children 
is to a great extent a community affair 
varying with the prevalence of tubercu- 
losis in the community or city. In Vienna, 
for instance, it is well known that the dis- 
ease is rampant and almost every child can 
be considered a contact. About one fifth 
of all deaths in Vienna are due to tubercu- 
losis, therefore, it has been thoroughly 
proven that we could not adopt the sta- 
tistics of Vienna as being indicative of the 
prevelance of the disease in this country, 
yet we know that the prevelance of this 
disease in our country, and in this state, is 
alarming. It is estimated that we have 
constantly in our state from twenty to 
thirty thousand cases of active tubercu- 
losijs. Now if we will just consider for a 
moment the thousands of little children 
who are being exposed daily to these active 
cases and at the same time realize that it 


Garrison — The Control of TuhercuLosis in Infants and Children 


97 


is practically impossible for a young child 
or infant to be continually exposed in this 
manner and escape the infection, then we 
will begin to see the seriousness of our 
problem. 

The prevention of tuberculosis in in- 
fancy and childhood should begin first in 
the prevention of marriage between tuber- 
culous individuals, or if married, to prevent 
the conception of children. Now let it be 
understood that we are not so radical as to 
say that we should prevent the marriage 
and conception of children in the appa- 
rently cured or arrested case. Neither 
man nor woman has a right to marry when 
actively ill with tuberculosis, but they may 
marry and have children when the disease 
is cured or apparently has been arrested. 
A thorough physical examination by a 
competent physician at least every three or 
four months is advisable in such cases. 
After such examinations the physician 
should offer such advice as he deems 
proper. If a woman who is pronounced 
actively tuberculous becomes pregnant 
she should receive the very best of care be- 
fore, during and after labor. The labor 
should be handled in such a manner as to 
prevent the exhaustive bearing down ef- 
forts which are likely to produce pulmonary 
hemorrhage or flare up an old arrested 
case. In such cases when the child is 
born it should be immediately removed 
from the mother and placed in a healthy 
environment or with a foster mother. The 
tuberculous mother should never nurse her 
baby and close contact of mother and child 
must be strictly avoided The infantorium 
idea properly supervised by a competent 
pediatrician would be almost ideal for 
such cases but the same work may be done 
in our modern well managed preventor- 
iums. 

The work of Prof. Calmette leads us to 
hope that more frequent employment of his 
clinical work with B.C.G. (non-tuberculo- 
genic modified bacillus) will perhaps en- 
able the situation to be mastered as far as 
it concerns the newly born baby of tuber- 


culous parents. According to Calmette, in 
France alone, up to January 1, 1926, five 
thousand, one hundred and eighty-three 
nurslings have been vaccinated by mouth, 
one thousand three hundred and seventeen 
of them within the last six to eighteen 
months. The mortality from birth to one 
year of infants of tuberculous mothers or 
of those in infected families is at least 25 
per hundred and frequently much higher 
but that of infants protected by B.C.G. is 
less than 2 per hundred. This method of 
immunization is harmless. It does not 
even involve danger of accident, febrile 
reaction or physilogic disturbance. The 
duration of conferred immunity cannot as 
yet be determined but it appears to be long 
enough to protect the children from family 
contamination until after they are three 
years of age provided the contagion is not 
too massive. This vaccination should 
not cause any one to dispense with any 
hygenic measures which are capable of 
preventing or lessening massive infection. 

Although we have in Mississippi but a 
very few tuberculous cattle it goes without 
saying that all dairy cows at least should 
be tuberculin tested at regular intervals 
and all tuberculous cattle removed from 
the herd at once. Just at this point it is 
well to say that raw or unboiled milk has no 
place as a proper food for babies under one 
year of age. All cows’ milk should be boiled 
or at least pasteurized before being fed to 
babies under one year of age. All anemic, 
undernourished or underweight children 
and all contact children should receive the 
skin or intracutaneous tuberculin test. 
The positive reaction indicates the exist- 
ance of tuberculous infection, not neces- 
sarily the existence of clinical tuberculosis. 
If the reaction is positive or if the clinical 
symptoms indicate tuberculosis the usual 
hygienic dietietic treatment should be insti- 
tuted at once. 

The diagnosis of tuberculosis in children 
is a rather difficult job. The signs and 
symptoms upon which a diagnosis can be 
made of early tuberculosis are indeed very 


98 


Garrison — The Control of Tuberculosis in Infants and Children 


few. The diagnosis of early tuberculosis 
is important from the social aspect and 
also from an economic point of view. It 
should be given the attention it deserves 
not only from the specialist but from the 
general practitioner as well because it is 
the latter who will necessarily have the 
greatest responsibility in the premises. 
Unfortunately little has been written on 
the subject of the diagnosis of tuberculosis 
in infants and children. The medical 
schools have been woefully negligent along 
this line of teaching. There remains much 
confusion and differences of opinions as 
to what constitutes a basis for diagnosis of 
incipient tuberculosis in children. There 
is a great demand by the pediatrician for 
more light on the subject. It is obvious 
that if progress is to be made in combat- 
ting this much dreaded disease that it 
must be diagnosed at the earliest possible 
moment after infection has occurred. It 
is still more obvijous that if further pro- 
gress is to be made in adult tuberculosis, 
we must necessarily make the diagnosis 
during childhood, at which time the infec- 
tion takes place. The reliability of the 
intradermal or even the ^kin tuberculin 
test of today need not be doubted. Out of 
80 patients given the cutaneous tuberculin 
test by L. Cummins on known cases of 
tuberculosis a positive reaction was noted 
in all except three, a total of 96.2 per cent. 
Those that gave doubtful or negative tests 
were severely ill with advanced tubercu- 
losis and died within three months. Von 
Pirquet says that in cases presenting clini- 
cal evidence of tuberculosis the reaction is 
positive in almost all instances after 
twenty-four hours. J. Claxton Gittings 
and John D. Donnelly conclude that a posi- 
tive tuberculin reaction does not occur in 
the absence of a tuberculous infection. 
However, there are instances when a child 
with a tuberculous infection does not react 
to tuberculin ; namely, first — incubation 
period of tuberculosis; second — acute tu- 
berculous infection with marked constitu- 
tional symptoms; third — miliary tubercu- 
losiis, tuberculous menengitis, advanced 


pulmonary tuberculosis and during certain 
infectious diseases such as measles, 100 per 
cent, scarlet fever 84 per cent, diphtheria 
12 per cent and others as pneumonia, in- 
fluenza, erysipelas, typhoid fever, and dur- 
ing tuberculin therapy. That a positive 
tuberculin test reveals a latent tuberculous 
infection i(s unquestioned. It is also posi- 
tively conceded that a positive tuberculin 
test in an i,nfant and a very young child 
usually implies an active tuberculosis. Tu- 
berculosis of childhood, particularly be- 
tween the ages of six to ten years, is a 
disease of the lymph glands involving 
mostly the tracheobronchial glands; apical 
lesions rarely occur before ten years of 
age. Slater found that the younger child 
showed involvment of the hilum glands 
and that the older child beginning with 
eleven years showed lung involvment. R. 
Gutterback states that hilum involvment 
is the most common form of tuberculosis 
in childhood. It is of great importance to 
appreciate that, at least in early tubercu- 
losis of childhood, the hilum glands are the 
only seat of infection. This, therefore, 
will produce little or no physical signs 
other than the D’Espine. The paren- 
chyma not being involved in incipient cases, 
physical signs will therefore be absent. If 
one awaits the presence of physical signs 
in the chest and tubercle bacilli in the 
sputum to diagnose tuberculosis in child- 
hood he will only diagnose the advanced 
cases or those who have already evolved 
into the adult type and for whom the prog- 
nosis is very grave. 

The roentgen-ray helps us but very little 
in the diagnosis of incipient hilum tuber- 
culosis. It will show us the presence of in- 
filtration with increased density and the 
presence of nodules, but it is difficult for 
the radiologist to differentiate the type of 
infection. It is well to remember that 
there are many causes for tracheobronchial 
adenitis, for instance in whooping cough, 
measles, bronchopneumonia, influenza, 
chronic bronchitis, lues, Hodgkins disease 
and asthma. Now to summarize the main 
points i)n diagnosis, I will say, that it is 


Garrison — The Control of Tuberculosis in Infants and Children 


99 


generally accepted that, first, a positive 
tuberculin test in a child under ten years 
of age is of much significance and should 
be given due consideration ; second, exclud- 
ing the conditions noted in this paper a 
persistent negative tuberculin test indi- 
cates the absence of a tuberculous infec- 
tion; third, excluding tuberculous lesions 
of the bone and other organs tuberculosis 
in children is essentially a tracheobron- 
chial adenitis with little or no physical 
signs except for a positive D’Espine; 
fourth, the presence of tracheobronchial 
glands does not necessarily mean tuber- 
culosis and a negative tuberculin test is of 
great importance in differentiating; fifth, 
children with incipient tuberculosis are 
not necessarily underweight, yet it is gen- 
erally considered that malnourished and 
underweight children are potentially tuber- 
culous; sixth, sixty-four to eighty-one per 
cent of school children between the ages 
of 5 to 14 years who give a definite history 
of contact become infected ; seventh, a defi- 
nite history of contact, the presence of 
enlarged tracheobronchial glands and a 
positive tuberculin test are sufficient 
grounds to make a diagnosis of incipient 
tuberculosis in children. Now with con- 
vincing statistics that the prevalency of 
tuberculosis is alarming, and with evidence 
that about 75 per cent of all children who 
come in contact with the disease actually 
becoming infected, surely we may conclude 
that the task before us is to prevent ex- 
posure to open or active cases. 

Children showing the signs of glandular 
tuberculosis should be treated with helio- 
therapy as a prophylactic measure as early 
as possible. Natural sunlight is prefer- 
able but when it is not available artificial 
light therapy may be used. General physi- 
cal therapeutics should be combined with 
general hygiene and prophylaxis against 
rickets and general glandular tuberculosis 
which always include pure cod liver oil. 
The preventorium or open air schools are 
of paramount importance. All anemic or 
pretuberculous, undernourished, actually 


tuberculous, or rachitic children should 
have access to the open air school or pre- 
ventorium. It has been shown that 
children who attend open air class, al- 
though they have fewer lessons, advance 
in their studies and often even surpass 
children who spend from five to six hours 
in the stuffy class rooms of the average 
schools. Midday luncheon, composed of 
nourishing food with a liberal amount of 
pure, wholesome milk, warm, well prepared 
gumbo soup and buttered toast is strongly 
advocated. Mental training of children 
must not be had at the expense of sound 
physical development. The greatest dan- 
ger of tuberculosis in the weak, predis- 
posed, anemic or underfed child comes 
with the approach of, and during the 
adolescense period. Prophylactic work in 
this type is particularly deficient. Long 
hours in badly ventilated class rooms, in 
college lecture halls, in store or warerooms 
and lack of proper recreation, irregular 
meals often insufficient in quantity and 
quality and unsanitary living in general 
are leading factors in the development of 
tuberculosis in the adolescent. According 
to statistics of the New York Tuberculosis 
and Health Association in 1924 there were 
17 deaths from tuberculosis among boys 
aged from 10 to 14 years, 44 deaths among 
girls of the same age; 116 deaths among 
boys of 16 to 19 and 227 deaths among 
girls of the same age. Aside from the 
causes already mentioned the greater tu- 
berculosis mortality among girls may be 
due to the foolish fad of trying to appear 
slender. It is suggested that many of the 
hard working girls who have good appe- 
tites follow these restrictions of under- 
nourishment intentionally. As a result of 
such practices it is suggested that if they 
have latent tuberculosis or undergo pro- 
longed contact with tuberculous persons, 
they are almost bound to acquire the dis- 
ease. There is urgent need in our state 
for the erection, proper maintenance and 
management of preventorium, open air 
schools, and summer camps. A crusade 
against, •thi's foolish fad of undernourish- 


100 


Garrison — The Control of Tuberculosis in Infants and Childre^i 


merit on the part of our girls and general 
encouragement to drink more pure whole- 
some milk from tuberculin tested cows is 
of value at this time. In this instance it 
is of interest to mention a startling reve- 
lation made by a milk survey which was 
inaugurated by our very efficient state 
health officer a few months ago. Now 
listen, please, at the reading of this para- 
graph from his report. “The average 
per capita consumption of milk for the 
eleven cities was found to be exceedingly 
low, being only 33 hundredths of a pint. 
The highest per capita consumption was 
56 hundredths of a pint”. Now just think 
of this. Certainly we need to emphasize 
the importance of drinking an abundance 
of good wholesome milk. Physical condi- 
tion also should be considered in a choice of 
occupation for young people. A thorough 
physical examination should precede the 
choice of any occupation for boys and girls. 
Annual periodic health examintions for 
every child and adult is the greatest safe- 
guard against the development of tubercu- 
losis in children and the most effective 
means of combating tuberculosis in adults. 
We must remember that the child of today 
is the man and the citizen of tomorrow. 

Let us put our shoulders to the wheel 
and help the Board of Health push any 
well organized plan of disease prevention 
and more especially seek sufficient appro- 
priations for our institutions for the pre- 
vention and cure of disease. Education of 
the masses in the methods of prevention of 
tuberculosis in infancy and childhood as 
w'ell as in the adult will untimately lead to 
victory. 

DISCUSSION. 

Dr. Henry Boswell (Sanatorium) : Inasmuch as 
I do not know anything about tuberculosis and 
the control of it, I shall be brief in my discussion. 

The control of tuberculosis in this State was 
studied very carefully many years ago. Dr. Gar- 
rison, who has just read this excellent paper, was 
a member of the Board of Health at that time and 
understands and knows the plans on which the 
work was originally started — to have our institu- 
tion down at McGee' as a center of education, 
bringing in the people as .;jaj)idly.’as.‘we' coujd 


educate them to other methods of control of the 
disease. He has discussed here control of the 
incidence of the disease among the people of this 
country. Of course, we have not anything like 
the incidence of the disease in European coun- 
tries, especially since the close of the war. 
Another thing that lowers the incidence of the 
disease in our State is our ti’emendous negro 
population. That statement will probably sur- 
prise you; but the incidence of tuberculosis among 
the negroes is nothing like the incidence of the 
disease in the whites, for the reason that a negro 
developing the disease dies quickly and is out of 
the way, while a white developing the disease 
may caiTy it for forty or fifty years, being a 
carrier all that time and spreading it to the young 
life. 

It is quite possible, we know, that every case is 
not a childhood infection, because if you^ are 
exposed to an overdose of tubercle bacillus or any 
coccus you may develop the disease. There is no 
such thing as absolute immunity; if a sufficient 
dose of any germ is given at one time to any indi- 
vidual he will come down with the disease. That 
accounts for acute tuberculosis in adult life. 
Most of our negroes have acute tuberculosis, and 
they may not develop it until fifty or sixty years 
of age. He has not carried it from childhood; a 
slight infection today with him is a tremendous 
affair tomorrow. 

The prevention of the disease in children is a 
widespread thing; it is a community proposition. 
If it is in the community the children are ex- 
posed to it, regardless of whether or not it is in 
the home. A physician in New York found that 
positive von Pirquet reactions were higher in the 
children where no positive history of contact in 
the homes could be elicited. It is the carrier that 
is carrying it about and extending it to them. 
Calmette’s work offers probably one of the most 
pleasing looking things now'. While the United 
States has not taken hold of it, except in isolated 
cases, yet the Dominion of Canada has on now 
a tremendous compaign over a large territory 
and in a large population to work out Calmette’s 
beginning experimentation. Dr. Calmette has 
been working on this for more than forty years 
now, and it looks as if the old man in the evening 
of his life is going to give us something worth 
while. I get his reports every month from Paris. 
While it will take twenty-five or fifty years to 
decide how long the immunity he has established 
will last, yet it will be a wonderful thing. I 
heard one physician stand up and make this posi- 
tive statement — when any man can make a phy- 
sical examination and say this child has pul- 
monary tuberculosis, he is too far advanced to 
save; if a radiologist can say this child has pul- 
monary tuberculosis, he is too far gone to save. 


Garrison — The Control of Tuberculosis in Infants and Children 


101 


But, as Dr. Garrison said, when you have a his- 
tory of contact and evidence of a beginning sick- 
ness in the child, begin treatment against tuber- 
culosis right away. In the children I have in the 
sanatorium we have only two that show positive 
physical signs in the chest, and both of them are 
hopelessly ill. They look like healthy children, 
but if we let them get up out of bed for a little 
while and walk over to the dining room, the next 
day they will be very sick children. 

We have a wonderful lot of research work 
going on, and I wish I had time to tell you about 
it. The treatment of the disease in children is 
just what Dr. Garrison told you. Remember that 
codliver oil and sweet milk contain the vitamin 
(A) which is necessary not only for cure, but for 
prevention. He mentioned in the paper that 
probably the desire on the part of young girls to 
be slender is responsible for the increase in tuber- 
culosis. There is no question that it is respon- 
sible. In five years in Mississippi the only in- 
crease in one age group in tuberculosis is in 
young people between the ages of fifteen and 
twenty-two — the age when they are out in auto- 
mobiles riding around, stopping at drug stores to 
get a drink at meal time, the age when they want 
to be so miserably slender. There is no question 
about it. 

Some of you fellows may get to think that I am 
more incompetent than I am as the head of your 
institution. From the State’s standpoint, that in- 
stitution is the beginning of a campaign to control 
tuberculosis. The disease will never be controlled 
by treating anybody’s individual case. The treat- 
ment of the thing is incidental to its control, and 
the State is in it to control it in the future; other- 
wise the State has no business in it. We are 
spending thousands of dollars a year, and unless 
we treat it with the idea of its future control we 
are pouring money in a rat hole, and there is no 
sense in it. That institution is built ahead of the 
game. It is built to treat tuberculosis, because 
you fellows and the public demand that the indi- 
vidual case be treated. The first thing we should 
start out with is a preventorium, but if we did 
we could not get you fellows to send the little 
children to us. We need another thing, and that 
is a home for the incurable cases, particularly for 
the indigent negro, who is carrying the bacilli 
to your children and mine. Our sanatorium 
stands on that foundation, and we want you fel- 
lows to wake up to that paper presented by Dr. 
Garrison — that we are planning for the future. 
Remember, when you are applying to me to admit 
patients to that institution, when you are looking 
at the patient’s side and your heart is bleeding 
for him, so is mine, more than yours, because I 
have fought the battle, I have been through the 


game; but I have to look at it from the viewpoint 
of ten or fifteen years from now and scatter them 
over the State of Mississippi so that they will be 
apostles of better living. One of the doctors said 
yesterday the best helper he had in his com- 
munity was a returned patient who went around 
and visited his patients and taught them how to 
live and how to take the cure. 

I hope you will carry that thought v/ith you, 
that the institution down here is the beginning 
of a campaign to control tuberculosis, that it is 
an educational institution. You come to me and 
say that you have a patient who is infecting 0 . 
whole family; that he is dying with tuberculosis 
and you don’t think I can cure him, but you want 
me to take him out of that community. But that 
is too late; he has already infected everybody. 
It will do no harm to let him stay six months 
longer and die among his own loved ones. The 
fellow we want is the curable case that will go 
back and be a missionary in his own community. 

I want to express my appreciation to Dr. Garri- 
son. 

I heard it said yesterday that there are not 
more than four or five hundred cases in this 
State. I want to say that I have in my files 
down there, signed by you doctors of Mississippi, 
nine thousand reports of cases in which you found 
bacilli in the sputum and God knows how many 
more there are. 

Di’. Garrison (closing) : I don’t know that I 
have anything further to say. Dr. Boswell has 
kindly emphasized everything I have gone over. 
We are shoulder to shoulder in this fight. I take 
a little pride in and like to remind the associa- 
tion that really this institution is yours an>"way. 
The tuberculosis sanitorium is an infant of the 
State Medical Association. We started it down 
at Hattiesburg, at the meeting there. I was 
placed on the committee. Dr. Dan Williams and 
Dr. Leathers and I, and we fought the thing 
through the legislature, and it is really your 
child. As Dr. Boswell says, it is a mere begin- 
ning. I want to say in defense of Dr. Boswell’s 
work (if it needs any defense; it does not from 
men who know the character of the work he is 
doing) that he is doing the best work in the 
United States today; there is no doubt about it. 
If any of you gentlemen have any sympathy with 
the criticisms that have been passed out here, you 
are entirely wrong, and you will regret it in the 
days to come. So let’s get in this fight and put 
it over and prevent the little child and the infant 
from being exposed. That is the focus of this 
work. 

I want to thank Dr. Boswell and all you gen- 
tlemen for the interest that you have displayed. 


102 


OCHSNER — Subphrenic Abscess 


SUBPHRENIC ABSCESS.* 

ALTON OCHSNER, M. D., 

New Orleans. 

Of the various late complications follow- 
ing a suppurative process within the 
abdominal cavity, a subphrenic abscess is 
one of the most feared. This abnormal 
condition was first described by Barlow, in 
1845, who distinguished it from pul- 
monary lesions. Leyden, in 1886, again de- 
scribed the clinical picture of subphrenic 
abscess. Unfortunately, the clinical pic- 
ture described by these two pioneers, very 
commonly, is considered the classical pic- 
ture of subphrenic abscess today, that is, 
the liver dulness is covered by a tympanitic 
zone, which, in turn, is covered by a zone 
of dulness produced by a pleural exudate. 
The tympanitic zone is produced by a gas 
bubble in the subphrenic abscess floating 
on top of the purulent exudate. This de- 
scription represents only a terminal stage 
of the condition, and if these signs are 
anticipated, many cases of subphrenic 
abscess will be overlooked, and also consid- 
erable time will have been lost in the 
treatment of the patient. 

The first operation for subphrenic abscess 
was recorded by Volkman, in 1875. Since 
this time, much has been written concern- 
ing the subject, especially in regard to the 
anatomy, pathologj^, symptomatology, and 
treatment. 

The anatomy of the subphrenic space was 
worked out by two French observers. Mar- 
tinet, in 1895, and Piquands, in 1910. 
Barnard, in 1908, classified the subphrenic 
spaces in much the same manner as Marti- 
net. Martinet described six subphrenic 
spaces, two located betweefr the liver and 
diaphragm, one on each side of the mid-line 
and separated from each other by the falci- 
form ligament. On the under surface of the 
liver were four spaces, one on the right, 
which is bounded on the left by the hepato- 
duodenal ligament, three on the left — one 

*From the Department of Surgery, School of 
Medicine, Tulane University, New Orleans, La. 


in the lesser peritoneal sac, another be- 
neath the liver anterior to the lesser 
omentum, and a perisplenic space located 
around the spleen. Barnard described five 
spaces — two on the right and three on the 
left; on the right an anterior subphrenic 
space located between the liver and the 
diaphragm and a posterior subphrenic 
space on the under surface of the liver; on 
the left, a space anterior to the lesser 
omentum, the perigastric space; a peri- 
splenic space, and the lesser peritoneal 
cavity. 

As these classifications did not seem to 
cover the cases clinically, several years ago 
Nather and I, while in Clairmonts Clinic, 
devised anotomically on the cadaver the 
following classification, which fits most 
cases of subphrenic abscess clinically: 

In a surgical sense we can consider a 
subphrenic abscess as a localized inflamma- 
tory process in one of the spaces located 
between the diaphragm above and the 
transverse colon below. This area is di- 
vided by the liver into an infra — and a 
suprahepatic portion. The suprahepatic 
space is located between the diaphragm 
above and the superior surface of the liver 
below. It is again divided into a right and 
left space by the falciform, or suspensory 
ligament, the lower free edge of which is 
the round ligament which continues to the 
umbilicus. The coronary ligament, which 
is the reflexion of the peritoneum from the 
under surface of the diaphragm onto the 
superior surface of the liver, divides the 
right superior space into an anterior and 
posterior space. The left prolongation of 
the coronary ligament, which is known as 
the triangular ligament or left lateral liga- 
ment, passes backward to lie at the pos- 
terior edge of the left lateral lobe, so that 
on the left side there is only an anterior 
superior space. The right prolongation, or 
the right late;ral ligament, passes' some- 
what anteriorly, dividing the right superior 
space into a large anterior and a small 
posterior space. The retroperitoneal space 
consists of that area enclosed within the 


OcHSNER — Sulyphrenic Abscess 


103 


limits of the coronary ligament, and is in 
contact with those portions of the liver and 
diaphragm which are not covered by 
peritoneum. 

The infrahepatic space, which is that 
located between the liver above and the 
transverse colon below, is divided into a 
right and left inferior space by the round 
ligament and the ligament of the ductus 
venosus. The left inferior space is again 
divided into an anterior and a posterior 
space by the lesser omentum, the space 
lying posterior to the lesser omentum is the 
lesser peritoneal cavity, and that lying 
anterioly is known as the left anterior in- 
ferior space. 

ETIOLOGY. 

The etiology of a subphrenic abscess is 
aften varied. By far the greater per- 
centage of cases, however, follow an acute 
infectious process somewhere within the 
peritoneal cavity. It is possible, though, 
to have an infection occur in the sub- 
phrenic space from some focus not within 
the abdominal cavity, or there may be ex- 
tension from some adjacent viscus, which 
is also not within the abdominal cavity. 
A.S stated, however, suppurations within 
the peritoneal cavity are responsible for 
most of the cases. It might be said that 
any condition giving rise to either a gen- 
eral or localized peritonitis is potentially a 
subphrenic abscess. This, undoubtedly, is 
a very radical statement, but still I feel if 
we consider the possibilities offered us that 
fewer failures in diagnosis will be made. 

Of the various suppurative lesions giv- 
ing rise to a localized infection in the 
subphrenic space, an acute appendicitis, 
possibly because of its greater frequency, 
is the most common offender. The per- 
centage varies considerably according to 
different observers. Fifield and Love, in a 
series of 78 cases, had 30 which followed 
an acute appendicitis, giving a percentage 
of 38.4. Lance had a percentage of 20, 
while 66 per cent of Clendening’s cases 
were caused by appendicitis. The second 
most frequent intra-abdominal lesion which 


is responsible for a subphrenic abscess is 
a perforation of either a gastric or duo- 
denal ulcer. In Fifield and Love’s series 
of cases this was responsible for 20 per 
cent. Suppurative lesions of the other 
viscera, such as the liver, gall-bladder, 
spleen, large intestine, and pleura are also 
responsible for subphrenic infections, but 
to a less degree. 

Infection may gain entrance to the sub- 
phrenic space in a number of different 
ways. First, direct extension by way of 
the peritoneal cavity along the para-colic 
groove to the righ kidney pouch. This is 
probably the most frequent mode of en- 
trance. Second, through the lymphatics — 
either the peritoneal or retroperitoneal 
lymphatics. Third, by the portal system. 
In this type of case there is a pylephlebitis 
with a production of a liver abscess which 
ruptures into the subphrenic space. Fourth, 
a rest abscess. Following a general peri- 
tonitis the remainder of the peritoneal 
cavity may be able to take care of the in- 
fection, but in the subphrenic space there 
remains a localized process which goes on 
to abscess formation. Ullman and I^evy 
believe those infections which occur as 
the result of direct extension are located 
intraperitoneally, those which follow ex- 
tension through the cellular tissues are 
retroperitoneal, and those which extend by 
the lymphatic system may be either intra- 
or extra-peritoneal. 

There is some variance in the opinion of 
various observers as to the type of causa- 
tive organism most frequently found in 
subphrenic abscess. Allen states that even 
though most of these abscesses follow an 
appendiceal infection, the staphylococcus is 
the offending organism in almost all cases. 
Fifield and Love found the colon bacillus 
in 33 per cent of their cases and an equal 
percentage contained staphylococci. Strep- 
tococci were responsible in about 1 per 
cent and aibout 2 per cent were sterile. 
Our experience has shown, however, that 
the B. coli is the most frequently found 
organism. 


104 


OcHSNER — SuhTphrenic Abscess 


PATHOLOGY. 

The pathology depends entirely upon the 
resistance of the individual and the viru- 
lence of the organism. Undoubtedly 
many cases of subphrenic inflamma- 
tion and infection occur which go on 
to resolution and do not give the signs and 
symptoms of a subphrenic abscess. These, 
in my mind, are much more frequent than 
the cases of subphrenic abscess. Lee, in 
1915, reported four such cases of subdia- 
phragmatic infection which did not go on 
to abscess formation. In all four cases 
there were sufficient clinical signs and 
symptoms to make a diagnosis of sub- 
phrenic infection. All, however, recovered 
spontaneously. In one, a first stage opera- 
tion and a transpleural drainage was done. 
The patient’s symptoms, however, cleared 
up before the second stage operation. 
Clendening reports another case of sub- 
phrenic inflammation which subsided 
spontaneously. In this same report he de- 
scribes another unusual manifestation of a 
subphrenic inflammation, and that is, 
serous effusion in the subphrenic space. A 
patient with signs of subphrenic abscess 
was operated on for an acute cholecystitis. 
An empyema of the gallbladder was found, 
and in the subphrenic space between the 
liver and the diaphragm there was a large 
collection of serous fluid. Ever since my 
attention was directed especially to this 
condition by a case observed in 1922, which 
was described in detail in a previous pub- 
lication, I have become convinced that an 
inflammation of a subphrenic space is not 
an infrequent accompaniment of a suppui'- 
ative process within tbe abdominal cavity. 
It is certainly a much more frequent com- 
plication of a ruptured appendix than 
Allen would lead us to believe. He states 
that the incident of production of sub- 
phrenic abscess following appendicitis is 
between three and four-tenths of one per 
cent. One per cent of all cases of rup- 
tured appendix is the figure given by 
Dexter as the incidence of subphrenic 
abscess. 


To demonstrate this point further, I wish 
merely to report rather briefly a proven 
case which has been observed within the 
last six months. A female, aged 22, was 
admitted to the hospital because of abdom- 
inal pain. She stated that three days 
previously, shortly after her noon meal, 
she was taken with rather a severe pain 
in the epigastrium, which radiated to the 
right lower quadrant. Shortly after this 
she vomited. The pain persisted in the 
right quadrant, but within the last twenty- 
four hours she experienced a pain in the 
right upper quadrant also. There were no 
chills. The vomiting persisted. Physical 
examination revealed nothing of interest 
except a slightly distended abdomen, dis- 
tinct tenderness and rigidity throughout 
the whole right side of the abdomen, for 
the most part over McBurney’s point and 
in the right upper quadrant and in the 
right flank. There was also a rebound ten- 
derness. Because of the rather typical 
history and physical findings, it was 
thought that the girl was suffering from 
acute appendicitis with an associated 
cholecystitis. Conservative therapy was 
decided upon because of the acute cholecys- 
titis, and the patient was treated with rest 
in bed and hot applications to the abdomen. 
The acute symptoms rapidly subsided, so 
after about ten days a laparotomy was 
performed. The appendix showed all the 
stigmata of a recent infection, but much 
to our surprise, the gallbladder was ap- 
parently normal. In exploring the sub- 
phrenic space, however, a localized area, 
measuring about five centimeters in 
diameter, composed of fibrinous adhesions, 
was found between the under surface of 
the diaphragm and the liver. These adhe- 
sions were so fresh that they could be 
easily broken with the finger and were un- 
doubtedly the result of a subphrenic in- 
flammation which was subsiding. They 
easily accounted for the symptoms and 
signs which we found at the time of the 
patient’s admission to the hospital. The 
patient made an uneventful recovery. 


OcHSNER — Subphrenic Abscess 


105 


A supposedly frequent accompaniment of 
a subphrenic abscess is a pleural effusion. 
This pathologic condition is only frequent 
in those cases in which the condition has 
been allowed to progress for a sufficiently 
long enough time that either toxins or or- 
ganisms themselves, have passed through 
the diaphragmatic lymphatics into the 
pleural cavity. One should not wait 
until this complication develops before 
diagnosing a subphrenic abscess. Clute 
states that “it is almost always true that a 
simple serous fluid will be present in the 
chest when there is pus just beneath the 
diaphragm.” In six cases reported by 
Dexter the diagnosis of pleurisy was made 
before the diagnosis of subphrenic abscess. 
He 'remarks : “Obviously, it is highly de- 

sirable to drain the abscess before the 
structures above the diaphragm are in- 
volved. In reviewing the subject, as well 
as the cases which have come under my 
own observation, it is striking to know 
how seldom a diagnosis is made early 
enough to accomplish this.” Baumann 
states that an associated pleural exudate 
occurs in 20 per cent of cases. Those cases 
of subphrenic abscess which are compli- 
cated by a pleural effusion offer a much 
greater problem in diagnosis than those in 
which this complication is not present. 
The first two cases of subphrenic abscess 
which I observed I treated for several 
weeks as a post-operative pleurisy without 
any results. 

A certain small percentage of subphrenic 
abscesses contain air. These, however, are 
either late cases or follow the perforation 
of either a duodenal or gastric ulcer. The 
air results from gas producing organisms, 
or it may escape from one of the hollow 
viscera. Lockwood states that it is found 
in about one-third of all the cases. While 
this figure may be true of the more ad- 
vanced cases, it is certainly not true of the 
earlier lesions. The percentage given by 
Phillips is 50 per cent. Hodges has main- 
tained that abscesses containing air are not 
common. Berman gives the incidence as 
15 per cent. The earlier the diagnoses are 


made the lower the percentage of abscesses 
which contain air will be observed. 
For this reason, very little significance 
should be placed upon this finding as a 
diagnostic aid. 

Of the various subphrenic spaces most 
frequently involved in an inflammatory 
process, the small triangular shaped 
right, superior, posterior space is most 
important. It is the site of a localized in- 
flammatory process in from 38 per cent 
(Fifield and Love) to 50 per cent (Nather 
and Ochsner) of all subphrenic abscesses. 
Of those subphrenic abscesses occurring 
following a ruptured appendix, the right 
posterior superior space is involved from 
50 to 80 per cent of cases. The right an- 
terior superior space is the space next most 
frequently involved, and this is followed in 
frequency by the right extraperitoneal 
space. Very commonly, associated with an 
abscess in the right posterior superior 
space, is also an abscess in the right 
inferior or infrahepatic space. This com- 
bination I have seen in three cases. A 
similar case was described by Straus in 
1923. 

SYMPTOMATOLOGY AND SIGNS. 

The early symptoms of a subphrenic in- 
flammatory process are very vague and 
indefinite. Following a suppurative or an 
acute inflammatory process in the abdomi- 
nal cavity, the patient does not get along 
as well as one would naturally expect him 
to do. The temperature, instead of falling 
to normal, may persist and may, after a 
period of time, slightly rise. There may be 
little or no alteration in the pulse rate. A 
slight leukocytosis is practically always 
present. In those cases in which the right 
posterior superior space is involved there is 
a localized tenderness over the tip of 
the twelfth rib, which usually remains con- 
stant. The patient may complain of pain 
in this region, or the pain may be referred 
to the chest. If these physical signs and 
symptoms persist over a period of days and 
remain constant, a positive diagnosis of 
subphrenic infection may be made. There 


106 


OcHSNER — Subphrenic Abscess 


is an early and associated immobility of the 
diaphragm, later to be followed by an ele- 
vation of the diaphragm, which may at 
times reach up as high as the level of the 
third rib. As the condition progresses 
there develops a pleurisy with friction rub 
at the base of the lung which may be fol- 
lowed by a pleural exudate. It is at this 
stage that a diagnosis of pleurisy with 
effusion is most commonly made. 

The roentgen-ray is of great assistance 
in making a diagnosis of subphrenic ab- 
scess. Pancoast, who reports sixteen cases 
of subphrenic abscess in which the diagno- 
sis was made roentgenologically, states that 
in diagnosing this condition by means of 
the roentgen-ray it is of utmost importance 
to have a good clinical history. As brought 
out by LeWald, Pancoast, and O’Brien, the 
roentgenological findings are, briefly, as 
follows: There is an elevation of the dia- 

phragm on the affected side, much higher 
than is usually found in cases of simple 
pleural effusion. The diaphragm is immo- 
bile. There may be some retraction of the 
lung. In those rare cases in which air is 
found in the subphrenic space the diagnosis 
may be easily made, because of the absence 
of shadow between the pus below and the 
diaphragm above. In order to make use of 
this phenomenon, W. H. Stewart, of this 
country, and Schintz, of Switzerland, have 
even advocated the injection of aid into the 
subphrenic space in order to visualize 
the abscess. This procedure, however, is 
not without danger and should not be 
attempted. 

Douglas has emphasized the importance 
of taking radiographs in either the sitting 
or the standing position. If the patient’s 
condition is such that this is not feasible, 
an anterio-posterior plate should be made 
with the patient lying on the unaffected 
side. In this way, more can be told about 
the position of the diaphragm than an an- 
terio-posterior view with the patient lying 
on his back. In spite of a suggestive his- 
tory and in spite of positive roentgen-ray 
findings, a diagnosis of subphrenic abscess 


is very frequently delayed until very late, 
as illustrated by a case reported by Cottle 
in 192.3. The patient had had an append- 
ectomy and excision of a gastric ulcer, 
following which he developed symptoms 
and signs of a right sided pleural lesion. 
Roentgenograms showed, however, a high 
diaphragm on the affected side. The diagno- 
sis was disputed for three and a half 
months, and it was not until four months 
after the original operation that a diag- 
nosis of subphrenic abscess was made, 
which abscess was drained successfully 
with complete cure of the patient. 

In those doubtful cases of subphrenic 
abscess one is justified in attempting an 
exploratory puncture in order to see if 
fluid is within the subphrenic space. 
Ullman and Levy advocate an exploratory 
aspiration. Hirsch reports a case of a 
physician in whom twenty-three explora- 
tory aspirations were done without any 
result. On the twenty-fourth aspiration 
pus was obtained. He emphasizes the fact 
that if aspiration is to be done, that it 
should be done over the area of relative 
dulness, which is that produced by the 
fluid, and not over the area of absolute 
dulness which is produced by the liver. 
Allen and Douglas take a slightly more 
conservative attitude concerning explora- 
tory aspiration. They believe that in the 
doubtful case one is justified in aspirating. 
Lockwood and Hodges, however, condemn 
the practice of promiscuous needling, be- 
cause of the danger of infecting either 
the uninvolved pleura or peritoneum. I 
also feel that exploratory aspiration should 
never be carried out, except to de- 
termine the character of an exudate within 
the pleural cavity. No attempt should be 
made to aspirate a suspected cavity be- 
neath the diaphragm, unless everything is 
ready for operation, and then every pre- 
caution should be. taken to avoid injuring 
or penetrating the pleural or peritoneal 
spaces. In order to do this, it is advisable 
to insert the aspirating needle, which is 
attached to a dry syringe, in the posterior 


OcHSNER — Subphrenic Abscess 


107 


axillary line at the level of the spinous 
process of the first lumbar vertebra. The 
needle is directed upward and backward 
at an angle of less than forty-five degrees. 
Aspiration should be carried out during 
the introduction of the needle, so that there 
will be no danger of encountering an ab- 
scess and passing through it unrecognized. 
Under no other circumstances should an 
exploratory aspiration be done. 

PROGNOSIS. 

The mortality of all the subphrenic ab- 
scesses reported to date varies from 23 to 
100 per cent. Fifield and Love report a 
mortality of 50 per cent in all of their 
cases. Of the fifty-nine cases operated on 
there was a mortality of 32 per cent. 
Lockwood states that from 85 to 100 per 
cent of those not operated on die, whereas 
of all cases taken, whether operated or not 
operated on, the mortality is 56 per cent. 
Most patients who have been treated surgi- 
cally have a mortality from 23 to 40 per 
cent. The following percentages have been 
given by the various observers: Hodges, 

50 per cent; Eicher and Kidzey, 50 per 
cent; Baumann, 66 per cent; McEachern, 
operated, 33 per cent, not operated, 75 per 
cent; Tuft, 66 per cent; Lotsch, operated, 
33 per cent, unoperated, 100 per cent. 

From these figures it can be seen that 
under the present method of treatment the 
mortality in subphrenic abscess is ex- 
tremely high. It is because of this appall- 
ing mortality that the abdominal surgeon 
has come to fear the development of a 
subphrenic abscess. What is the cause of 
this high mortality? In analyzing the 
cases reported in the literature one is im- 
mediately impressed by two considerations : 
First: That by far the majority of cases 
are advanced and show extreme patholog}’' 
at the time the diagnosis is made. This 
means that the patient’s resistance has 
been so reduced by a long continued septic 
process and that a recovery is not as likely 
as in an individual whose illness dates back 
a comparatively short time. Were the 
diagnosis made and proper therapy insti- 
tuted earlier this high mortality would be 


reduced to a remarkable degree. The 
second fact that impresses one is that many 
of these patients operated upon develop 
signs and symptoms of either an empyema 
or a peritonitis, which, undoubtedly, is a 
factor in the cause of death. If the in- 
volvement of the pleural and peritoneal 
cavities is a cause in raising the mortality, 
is there any way in which we can prevent 
complications? 

naEATMENT. 

The treatment of subphrenic abscess 
may be divided into three different types : 

1. Prophylactic. The prophylactic treat- 
ment consists of placing all patients with 
a suppurative process within the peritoneal 
cavity in the Fowler’s position in 
order that the infectious material 
may gravitate into the pelvis. Large 
amounts of fiuids should be given, 
either under the skin or intraven- 
ously, which are, in turn, secreted into the 
peritoneal cavity, diluting the infectious 
material and washing the purulent mate- 
rial into the pelvis. The delayed or con- 
servative treatment of those cases of rup- 
tured appendix seen after thirty-six to 
forty-eight hours will prevent many cases 
of subphrenic abscess. This has been em- 
phasized by Fifield and Love. They found 
that in 228 cases treated conservatively at 
the London Hospital a subphrenic abscess 
occurred only in one case, while 1109 cases 
subjected to immediate operations, 7 were 
complicated by subphrenic abscess. During 
intraperitoneal operations it is of utmost 
importance to protect the general perito- 
neal cavity in order to prevent it from 
being sailed. Adequate drainage, especially 
in those cases where there is a localization 
of ';he process should be performed, which 
will undoubtedly reduce the incidence of a 
subphrenic abscess formation. 

2. Conservative treatment : It is essen- 
tial to diagnose a subphrenic infection as 
early as possible, so ‘ that the proper 
therapy may be instituted. In the case of 
a patient who has recently had a suppura- 
tive process within the peritoneal cavity. 


108 


OcHSNER — Subphrenic Abscess 


and whose condition does not clear up as 
well as might be expected, and one who 
presents the early signs of a subphrenic 
abscess, a diagnosis of a subphrenic in- 
flammation may be made and conserva- 
tive therapy instituted. The conservative 
treatment consists of keeping the patient 
as quiet as possible; immobilizing the 
affected side of the chest with adhesive 
plaster; applying heat to the affected side, 
either by electric pads, hot water bottles, 
or diathermy; and the building up of the 
general resistance of the patient. By far 
the greater number of subphrenic infec- 
tions will respond to this therapy. Fewer 
will go on to suppuration if the therapy is 
instituted early, instead, the inflammatory 
process will clear up by resolution. 

3. Treatment after the development of 
an abscess : Once a subphrenic abscess has 
developed, as evidenced by the hectic type 
of temperature, marked increase in leuko- 
cytes, and increase in amount of tender- 
ness over the affected area, which may or 
may not be accompanied by an edema, 
drainage of the abscess is indicated. The 
proper operative procedure employed de- 
pends entirely upon the location of the 
suppurative process. In the past, by far 
the greater number have been drained by 
the transpleural route, because of the high 
location of the abscesses, which virtually 
lie within the thoracic cage. Those abscesses 
lying anteriorly, and which tend to point 
anteriorly, have been drained through an 
anterior or trans-abdominal approach. 
Some few have been drained through the 
loin. While anatomically the transpleural 
and trans-abdominal routes may be the 
ideal procedures, they still have certain 
definite disadvantages, in that they require 
traversing one of the large serous cavities. 
While it is true, theoretically at least, that 
an infection of the serious cavity may be 
prevented by performing the operation in 
two stages, still statistics have shown that 
the results obtained from the use of these 
approaches are from satisfactory. Fifield 
and Love had a mortality of 43.7 per cent 
in those cases which were drained trans- 


pleurally, a mortality of 23.8 per cent in 
those drained through the anterior abdom- 
inal wall, and a mortality of 16.7 per cent 
in those drained through the loin beneath 
the twelfth rib. Lockwood, who states that 
the mortality of all the cases of subphre- 
nic abscess is between 23 to 40 per cent, 
believes, however, that it should not be 
higher than 16 per cent. As a protection 
against the development of empyema, he 
advises an intercostal incision, following 
which the intercostal muscles are sutured 
to the diaphragm. The skin edges are then 
mobilized and also sutured to the dia- 
phragm. In this way he believes that not 
only can a wound phlegmon be prevented 
but also an infection of the pleural cavity. 
Orsos, in Germany, advocates a similar pro- 
cedure in that in place of the one layer 
suture he used two layers, and believes in 
this way to be able to prevent an empyema. 
He reports two cases, both of which were 
cured. 

Within the past year McEachern has 
advocated the closed method of drainage, 
which consists of inserting a tube into the 
abscess cavity, usually in the tenth inter- 
space, an attempt being made to keep the 
connection air tight. The cavity is irri- 
gated with Dakin’s solution, according to 
the Carrel technique. He reports two 
cases, both of which were cured. One 
patient, however, developed an empyema 
following the drainage of the subphrenic 
abscess, which probably was due to an in- 
fection introduced into the pleural cavity 
at the time of the drainage. This is one 
of the great disadvantages of the method, 
because it is impossible to tell whether 
there are adhesions between the two layers 
of parietal pleura or not. McEachern 
mentions another disadvantage ; that is, 
multiple abscess pockets may be over- 
looked. He believes, however, that in the 
severe cases that the operative procedure 
is of decided value. 

THE RETROPERITONEAL APPROACH. 

In 1923 Nather and I described an ap- 
proach which is applicable, especially for 


OcHSNER — Suhphi'enic Abscess 


109 


those abscesses located in the right supe- 
rior posterior space — which is the most 
frequent location for a subphrenic abscess. 
The success of the retroperitoneal operation 
depends upon the fact that the peritoneum 
on the under surface of the diaphragm is 
only loosely attached to the diaphragm; 
also, that the peritoneum, as is reflected 
down from the under surface of the 
diaphragm is continuous below with the 
renal fascia. This loose attachment of the 
peritoneum to the under surface of the 
diaphragm is present in normal individuals 
and can be readily demonstrated on the 
cadaver, permitting an easy separation of 
the peritoneum from the diaphragm. This 
can be even more readily done in those 
cases where there is an inflammatory pro- 
cess in the subphrenic space, because of the 
edema which is located sub-peritoneally. 
The technique of the retroperitoneal oper- 
ation is, briefly, as follows: 

A skin incision is made over and parallel 
to the twelfth rib; the twelfth rib is re- 
sected subperiosteally throughout its whole 
length. A transverse incision through the 
soft parts is made at the level of the 
spinous process of the first lumbar-ver- 
tebra. In employing a transverse incision 
at this level the pleura will be sure to be 
avoided. The incision is carried through 
the musculature down to the renal fascia. 
The renal fascia is followed upward, above 
it is continuous with the peritoneum. 
Usually the free edge of the liver may be 
seen through the peritoneum. At this 
stage of the operation it is desirable to in- 
sert a needle into the subhepatic space, in 
order to determine whether an infra 
hepatic abscess in the right inferior space 
is present or not. If pus is obtained, the 
abscess is not drained, but this part of the 
wound is packed until an exploration of the 
supra-hepatic space has been made. Wide, 
broad, blunt retractors are now placed in 
the upper edge of the wound elevating the 
edges of the ribs and diaphragm. With 
the index finger of the right hand the 
peritoneum is separated from the under 
surface of the diaphragm. This occurs 


without any difficulty. The surface of the 
liver is explored with the index finger, and 
as soon as the abscess cavity, which cnn be 
easily felt, is located, the wall of the ab- 
scess is broken through with the finger, 
thus allowing evacuation of its contents. 
Two large fenestrated rubber tubes are in- 
troduced into the cavity and brought out 
through the wound to serve as drainage 
tubes. In those cases where pulmonary 
symptoms have been present before, it is 
desirable, before draining the supra-hepatic 
abscess, to aspirate the pleural cavity — 
which can be easily done in the costo- 
phrenic angle. If no pus is obtained at 
this aspiration nothing further is done as 
far as the pleural caviety is concerned. If, 
however, pus has been obtained from the 
pleural cavity, the empyema may be 
drained at the same time by opening the 
costophrenic angle just above the dia- 
phragm. A fenestrated rubber tube should 
then be inserted into the pleural cavity, 
also. 

The retroperitoneal operation is the 
operation of choice in those cases in which 
the abscess is located posteriorly, which is, 
as has been stated, the most frequent site 
of abscess formation. By this procedure 
the abscess is drained without traversing 
either of the large serous cavities, thus 
obviating the danger of either a perito- 
nitis or empyema. 

For those cases of subphrenic abscesses 
located anteriorly a similar approach, de- 
scribed by Clairmont, and spoken of as the 
pre-peritoneal operation, is the method of 
choice. This is carried out through a ten 
centimeter long incision over and parallel 
to the anterior costal arch. All the struc- 
tures are divided down to the peritoneum. 
If there is an abscess present, either in the 
inferior or superior space, the peritoneum 
shows a very characteristic change in that 
it is edematous and friable. The perito- 
neum is then dissected upward from the 
under surface of the diaphragm in a way 
similar to that done in the retroperitoneal 
operation. Broad blunt retractors are 


110 


OcHSNER — Stibphrenic Abscess 


placed above, elevating the diaphragm and 
the costal arch. After a separation of the 
peritoneum from the under surface of the 
diaphragm for a short distance, the infe- 
rior edge of the liver usually becomes 
visible. At this stage it is desirable to 
aspirate the infrahepatic space, in order 
to determine whether an abscess is present 
in his space or not. The superior surface 
of the liver is then explored with the finger, 
and after locating the abscess, it is drained, 
as in the retroperitoneal operation, by 
breaking through the pyogenic membrane 
with the index finger. The advantages of 
the preperitoneal operation are the same 
as those of the retroperitoneal operation. 
If pus is not located by means of either one 
of these approaches, very little harm has 
been done the patient. The wound can be 
sutured, and the subphrenic space explored 
through the other approach. 

CONCLUSIONS. 

1. Subphrenic infections are not infre- 
quent, and follow a large percentage of 
intra - abdominal suppurative processes, 
chiefly appendiceal. 

2. By far the greater number of sub- 
phrenic inflammatory processes subside, 
especially if proper therapy is introduced 
early, 

3. Careful clinical observation of a 
patient who has had a suppurative process 
within the peritoneal cavity will usually 
suffice to make a positive diagnosis of a 
subphrenic infection when such occurs. 
The roentgen-ray is a valuable aid in diag- 
nosing the condition. 

4. The treatment of a subphrenic infec- 
tion is divided into prophylactic, conser- 
vative, and radical methods. Most cases of 
subphrenic infection respond to conserva- 
tive treatment. 

5. In a subphrenic abscess an unin- 
volved pleural or peritoneal cavity should 
not be opened. 

6. The retro- and pre-peritoneal oper- 
ations are the procedures of choice, be- 
cause of the avoidance of the large serious 


cavities and the lack of shock caused by 
the operations. 

7. The mortality following the retro- 
peritoneal operations for subphrenic ab- 
scess has been 6 per cent. 

BIBLIOGRAPHY. 

Allen. Arthur W.: Discussion; An important complica- 

tion of acute appendicitis (Cabot case records). Boston M. 
& S. J., 194:1097-1099, 1926. 

Barlow, G. H. ; Perforation of the stomach, with obscure 
thoracic symptoms. London M. Gaz., 36 :13-16, 1845. 

Barnard. H. L. : An address on surgical aspects of sub- 

phrenic abscess. Brit. M. J., 1:371-429, 1908. 

Bauman, M.: Subphrenic abscess. Beitr. 2 . klin. Chir., 

128 :477-480, 1923. 

Berman, J. K.: Subphrenic abscess. J. Indiana M. A-, 

18:217-221, 1925. 

Clendening, L. : Subphrenic infection. Med. Clin. N. 

Amer., 7 :1147-1167, 1924. 

Clute, H. M.: Subphrenic abscess after appendicitis. Surg. 
Clin. N. Amer., 6:775-782, 1926. 

Cottle. G. F. : Subphrenic abscess. U. S. Nav. M. Bull., 

19 :683-685, 1923. 

Dexter. R. : Diagnosis of subphrenic abscess. Am. J. 5L 

Sc., 170:810-821, 1925. 

Douglas, J.: Subdiaphragmatic abscess and accumula- 

tions of fluid. Ann. Surg., 79:845-853, 1924. 

Eicher, C. G., & Kibzey, A. T. : Subdiaphragmatic ab- 

scess. Atlantic M. J., 28:30-32, 1924. 

Fifield. L. R., & Love, R. J. McN. ; Subphrenic abscess. 
Brit. J. Surg., 13:683-695, 1926, 

Hirsch, C. : Zur Technik der Probepunktion bei rechts- 

seitigen subphrenischev abszess. Mitt. a.d. Grenzgeb. d. 
Med. u. Chir., 35:595-597, 1922. 

Hodges, F. M.: Subdiaphragmatic abscess. J. A. M. A., 

80:1055-1058, 1923. 

Lang; Quoted by Piquands. 

Lee, Roger I.: Subdiaphragmatic inflamm.ation. J. A. M. A., 
16:1307-1310, 1915. 

LeWald, L. T. ; Subphrenic abscess and its differentia) 
diagnosis roentgenologically considered. Arch. Surg., 10: 
544-556, 1925. 

Leyden: Ueber pyopneumothorax subphrenicus (Und 

subphreniche abscesse). Ztschr. f. klin. Med., 1 :320, 1879. 

Lockwood. A. L. : Subdiaphragmatic abscess. Surg. 

Gynec. Obst., 33:502, 1921. 

Lotsche, F. : Subphrenic abscess. Klin. Wchnschr., 3: 

2013-2014, 1924. 

Martinet: Des varietes anatomiques d’abces souphreniques. 
Rev. gen. de din. et de therap., 3:145-147, 1899. 

McEachern, J. D. ; Closed drainage in subphrenic abscess. 
Surg. Gynec. Obst., 43:215-219, 1926. 

Nather, K. : Access to subphrenic abscess. Arch. f. 

klin. Chir., 122:24-99, 1922. 

Nather, K., & Ochsner, E. W. A. : Retroperitoneal oper- 

ation for subphrenic abscess. Surg. Gynec. Obst., 37: 
665-673, 1923. 


OcHSNER — Subphrenic Abscess 


111 


O’Brien, F. W. : Roentgenray diagnosis of subdiaphrag- 

matic abscess. Boston M. & S. J., 196:518-523, 1927. 

Orsos, E. : Modifications of transpleural access to sub- 

phrenic abscess. Zentralbl. f. Chir., 52:1637-1640, 1925. 

Pancoast, H. K. : Roentgenological diagnosis of liver ab- 

scess with or without subdiaphragmatic abscess. Am. J. 
Roentgenol., 16:303-320, 1926. 

Picquands, G. : Les abces sousphreniques. Rev. de chir., 

29:156-179, 1909. 

Stewart: Quoted by LeWald. 

Straus. D. C. : Transpleural drainage under paraverte- 

bral anesthesia. S. Clin. N. Amer., 3:925-939, 1923, 

Tuft, L. : Subphrenic abscess, clinical study. Am. J. M. 

Sc.. 170:431-441, 1925. 

Ullman, A., & Levy, C. S. : Subphrenic abscess, report of 

a case with cure. Surg. Gynec. Obst., 31 :594, 1920. 

Volltoian: Cited by Fifield and Love. 

DISCUSSION. 

Dr. J. A. Danna (New Orleans) : I believe you 
will all agree with me in that it is more difficult to 
discuss such a comprehensive monograph as the 
one that has just been read and my only reason 
for rising to do so is that I have been announced 
as the discusser. 

I think the paper is timely because it teaches 
us a lesson, teaches us that we are passing up 
diagnosing these cases and waiting until they are 
so far advanced that it very easily accounts for 
the bad name that a subphrenic abscess has. 
Whenever one speaks of a subphrenic abscess it 
implies a very sick patient: this should not be the 
case if the patient who is apt to develop a sub- 
phrenic abscess receives the personal attention 
that he should be given. Whenever a patient (as 
stated in the paper) has an abdominal infection 
and will not clear up, does not improve as he 
should, has a little fever, etc., look for evidence of 
a subphrenic abscess. If the paper does nothing 
more than call attention to the fact that many 
of these cases die because they are not diagnosed 
early and makes us watch more carefully in the 
future for this condition, it will have accomplished 
a great deal. 

The doctor brought out the fact that pleural 
effusion complicates these cases very often and 
that is where we go astray. When dealing with a 
pleural effusion we feel that the condition is in- 
trathoracic, above the diaphragm— we go on and 
treat the j/atient above the diaphragm and the 
condition gets worse. 

Speaking of aspiration. The doctor cites a case 
where aspiration was done twenty-four times be- 
fore finding pus. The reason why repeated at- 
tempts so often fail to demonstrate pus is be- 
cause it is very hard to get a needle large 
enough sometimes for pus to come through. Do 
not be satisfied even after you have stuck a large 
needle ki a supposed cavity if no pus is with- 


drawn; do not take it for granted there is no pus; 
the pus may be of a consistency that will not go 
through the needle. 

I have had some experience with the incision 
the doctor speaks of in approaching these cases 
through the costal arch. Make the incision on 
the costal border, split your soft tissues down to 
the rib and then sort of peel them from under the 
ribs; you will find that your peritoneum and pos- 
sibly some of the fibers of the diaphragm will sep- 
arate easily and you can reach up with the finger 
and get at the abscess between the diaphragm 
and liver very readily. I am sorry Dr. Oshsner 
did not go more into detail about that retroper- 
itoneal incision. We need not grope about getting 
into this abscess behind ; the technique worked out 
by Dr. Ochsner in 1923 is a very nice method 
which gives you a clean job and a very thorough 
result. 

As I said a while ago, it is rather difficult to 
say anything after everything has already been 
said. 

Dr. I. M. Gage (closing) : I have nothing in 

the way of discussion to add, but wish to thank 
the Society for the extension of time granted to 
complete the reading of Dr. Ochsner’s manuscript, 
and also thank' Dr. Danna for his discussion. 

After the meeting, to anyone who is interested, 
I will be more than pleased to demonstrate the 
retroperitoneal incision on the cadaver. 


BERIBERI (“MALADIE DES JAMBES”) IN 
LOUISIANA. — Four patients from the rice belt 
are reported on by Scott and Herrmann, sick with 
what they termed “maladies des jambes.” Of 
these, two had definite beriberi, while in the other 
two the picture of an acute nephritis predomi- 
nated. There were ten cases in the parish prison 
besides the four true cases of beriberi received 
at the charity hospital. One prisoner died on the 
way to the hospital from the jail and two were 
sent to Baton Rouge. Eight of those detained 
are said to have been relatively mildly affected 
and recovered when the diet was changed. Alto- 
gether, eight prisoners were admitted to the hos- 
pital with edema and questionable cardiac lesions, 
but three were undoubtedly not to be classed as 
having true beriberi. It may, however, be as- 
sumed that preexisting heart disease was adversely 
influenced by the nutrition. They conclude that 
“maladie des jambes,” the nutritional disturbance 
frequently encountered among the rice farmers of 
Louisiana, is identical with the neurodegeneratiye 
syndrome classed as the “wet” type of beriberi in 
oriental countries or the sporadic outbreaks of 
neuritic edema in prisons, asylums, on shipboard, 
or in war. The outbreak of jail beriberi and ag- 
gravated heart lesions in the parish prison was 
provoked by a monotonous diet, which, though 
plentiful enough, was deficient in essential vita- 
min constituents. Though authorities may still be 
divided on the true etiology, the authors consider 
a deficiency of vitamin B in the diet as the princi- 
pal cause. — J. A. M. A., 90:2083, 1928. 


112 


Cutting — The Treatment of Burns 


THE TREATMENT OF BURNS.* 

R. A. CUTTING, M. D., 

New Orleans. 

The responsibility of dealing with cases 
of burns is a legacy which has been handed 
down by tradition to the general surgeon — 
a bequest which, though apparently logical 
enough, he has too frequently accepted 
with diffidence or even reluctance. The 
temptation to esteem the spectacular and 
avoid the commonplace has operated to re- 
tard the progress of knowledge with 
respect to burns as in few other surgical 
conditions. 

DEFINITION. 

Burns have usually been defined as 
lesions caused by raising the temperature 
of a part to a degree incompatible with 
its normal functioning, or, more compre- 
hensively, as a special type of wound due 
to the action of heat, chemicals, electricity, 
or radiant energy. To this conception, as 
will be shown presently, one must add, as 
a result of the contributions of various 
fairly recent investigators, that toxemia is 
also an essential part of the picture. 

CLASSIFICATION. 

The classification of burns has been both 
according to the causative agent, as men- 
tioned above, and also according to the 
depth of the wound; most commonly three 
degrees of burns are described in the 
United States: (1) erythema, (2) bleb 

formation, and (3) eschar; occasionally 
Dupuytren’s classification into six degrees 
is preferred: (1) erythema, (2) dermati- 
tis, with bleb formation, (3) sub-total de- 
struction of the skin, (4) complete de- 
struction of the skin, (5) destruction of 
the superficial structures to, and including, 
the muscular layer, and (6) carbonization 
of muscles. 

It is at least questionable whether the 
action of radiant energy on tissues should 
be described as a burn. Probably such 


*Read before Orleans Parish Medical Society, 
January 23, 1928. 


lesions should be given a chapter of their 
own. 

Electrical burns have been shown, how- 
ever, by Schridde to present identically 
the same histological picture as burns 
caused by great heat, and accordingly fall 
properly within the classification. 

Chemical burns are not much different 
from electrical-thermal burns histologi- 
cally, and are treated, except for minor 
modifications, in the same way. As side 
effects, acids combine with body proteins to , 
form acid-metaproteins, while alkalis form 
alkali-metaproteins; acids have the power 
markedly to soften connective tissue and 
epithelium, and alkalis the power to com- 
bine with tissue fats to form soaps ; further- 
more, both acids and alkalis are intensely 
hygroscopic, one acid, sulphuric, being able 
to withdraw hydrogen and oxygen from or- 
ganic compounds to leave carbon only and 
thus give the phenomenon of charring. But 
from a practical point of view these pecu- 
liarities of chemical burns are of no par- 
ticular significance. There is, however, one 
respect in which the effect, and conse- 
quently the treatment, of these lesions 
varies from type, and that is, that while 
the immediate destructive action of ther- 
mal burns ceases as soon as the burned part 
has had a chance to cool, the action of a 
chemical caustic, unless therapeutically 
stopped, is prolonged for a variable period 
of time until neutralized by the fluids com- 
ing to the tissues by way of the blood 
stream. 

The classification of burns according to 
depth of penetration, though useful in a 
general way, is clinically often not very 
satisfactory, mainly for two reasons: 
(1) The measure of the constitutional 
severity of a burn is frequently not so 
much its depth as its location and its sur- 
face area, and (2) the measure of the local 
severity is the ability of the lesion to heal 
without impairment of function, i. e., with- 
out scar formation, which, as Bancroft and 
Rogers, Goldblatt and others have shown, 
depends upon the destruction, not so much 
of the skin itself, as of the hair follicles 


Cutting — The Treatment of Burns 


1)13 


which dip below the skin proper. In other 
words, a so-called third degree burn in the 
usual classification will go on to extensive 
scar formation if it is so deep as to destroy 
hair follicles, but relatively complete res- 
toration of the integument will be the rule 
if undestroyed hair follicles remain to pro- 
vide small islands of epithelium from 
which epidermization may proceed. Ac- 
cordingly, it has been proposed to classify 
burns clinically in only two degrees : 
(1) Those which are so superficial as to 
have no marked tendency to scar forma- 
tion, and (2) those in which the depth of 
the lesion precludes such a possibility; 
whether such a classification is important 
enough to supersede the older ones remains 
to be seen. 

ETIOLOGY. 

The etiology of bums, perforce, has 
been already discussed in part, but with 
respect to age and sex incidence it is in- 
teresting to note that at least on the basis 
of mortality statistics taken from the 
figures compiled by the Metropolitan Life 
Insurance Company females seem to be 
affected more than males in the ratio of 
three to two, more males dying from 
burns from birth up to the age of three, 
more females from 3 to 35, males and 
females about equally again for a number 
of years, and later, in the old age period, 
more females than males. Perhaps this 
preponderance of fatal burns amongst 
females is not in accordance with what 
one might expect, but it can doubtless be 
explained satisfactorily in connection with 
the character of clothing worn, woman’s 
duties about the kitchen and the stove, 
and similar considerations. More burns 
occur in the winter than in the summer 
months, rather obviously because of the 
necessity for more numerous and hotter 
fires during cold weather. 

PATHOLOGY. 

The local pathological histology of 
burns need not be repeated here; it is so 
classical as to constitute the type pic- 
ture of inflammation, but the constitu- 
tional reaction following these lesions is 


too little understood, and such knowledge 
as we have concerning it is altogether too 
infrequently emphasized. It has always 
been appreciated, of course, that the 
severity of a burn may be, and frequently 
is, out of all proportion to the amount of 
tissue actually destroyed, but just why 
this should be has been considerable of an 
enigma. In the past, surgery has been 
content simply to dismiss the constitu- 
tional reaction with the term toxemia. 
Because of certain researches, however, 
mostly of fairly recent date the surgeon 
of the present has been enabled to appre- 
ciate the nature of this reaction more 
intimately than his predecessors. It 
appears from the reports of a number 
of investigators, notably Robertson and 
Boyd and Ravdin, that the burning of skin 
causes the local formation of a toxic 
product or toxic products which remain 
confined to the region of the lesion for a 
matter of eight hours or so, but, unless pre- 
vented from so doing, thereafter find their 
way into the blood stream, enter into or 
become absorbed by the red corpuscles and 
produce an effect some aspects of which 
have been pointed out, but which is not 
completely explained as yet. The evidence 
is somewhat as follows: 

If the blood returning from the burned 
extremity of an experimental animal be 
diverted into the blood stream of a normal 
animal, the latter soon thereafter develops 
toxic symptoms the counterpart of those it 
would have manifested had it been burned 
itself. 

If, instead of injecting whole blood, only 
red corpuscles are transferred from the 
burned animal to the normal one the reac- 
tion occurs as before, but if plasma alone 
is given, no reaction takes place. 

If an area of burned skin from an ex- 
perimental animal be removed completely 
and grafted onto a normal animal within 
8 hours, the second animal, and not the 
first, develops the toxemia; if this is done, 
however, after the lapse of a longer interval 
both animals suffer. 


114 


Cutting — The Treatment of Burns 


The nature of the toxin elaborated by 
the burning of skin is unknown, but it has 
been definitely shown to be produced only 
when living skin is burned ; the provisional 
assumption is made that it consists of 
primary and secondary proteoses, and fur- 
ther analysis into thermolabile and ther- 
mostable constituents had been attempted. 

Organic pathology resulting from the 
toxemia has been sought grossly, micro- 
scopically, and chemically. 

Cases of rather severe burns character- 
istically present the blood picture of con- 
centration, which is most conveniently in- 
dicated and measured by the procedure of 
hemoglobin estimation. Underhill reports 
increases to 145 per cent of normal and 
Ravdin to 125 per cent, figures which call 
to mind the similar concentration observed 
in high intestinal obstruction, war gas 
poisoning, fulminating influenza, and 
Asiatic cholera; indeed the blood concen- 
tration may easily be the cause of death 
in cases of burns, the increased viscosity 
leading to impairment of the circulation, 
diminished oxygen-carrying ca,pacity, low- 
ering of temperature, and suspension of 
the vital activities. Underhill believes that 
this phenomenon can be explained on the 
basis of an outpouring of tissue fluid 
through the partially devitalized walls of 
the capillary bed in the region of the 
traumatism. 

The gross and microscopical pathology 
of the various body organs has been, on the 
whole, rather unproductive in cases of 
burns. Robertson and Boyd several years 
ago reported that they found evidences 
of parenchymatous degeneration in the 
various abdominal organs, but Weiskotten 
and Greenwald and Eliasberg, reporting 
on human autopsies, and Olbrycht, work- 
ing with experimental animals, were un- 
able to confirm these findings. Greenwald 
and Eliasberg, however, working with 
rabbits in an attempt to find a possible 
explanation for an extreme hypoglycemia 
which they had observed in two clinical 
cases of burns which had died (one had no 


blood sugar at all, the other only 30 mg. 
per 100 C.C.), have described certain 
changes in the adrenal glands which are 
interesting in that they suggest diminution 
of adrenalin secretion as a part of the pic- 
ture of burn toxemia,; for the first 24 hours 
following experimental burns they found 
evidences of increased cellular activity in 
the adrenals of their animals accompanied 
by hyperglycemia, which they interpreted 
as being caused by excess stimulation. 
Olbrycht previously had found pathology 
of the adrenals in animals subjected to 
burns, consisting of hyperemia, ecchy- 
moses, and reduction or total loss of 
chromaffin substance and lipoids. Hypogly- 
cemia, if due to exhaustion of adrenal 
cortex, should be amenable to treatment 
with hypodermic injections of adrenalin, 
and this should be borne in mind, together 
with the suggestion that according to the 
experimental data, such therapy would be 
contraindicated during the first 24 hours 
following burn trauma. 

Acidosis, it should be mentioned, is ap- 
parently no essential part of the toxemia 
incident to burns; the carbon-dioxide com- 
bining power of the plasma is normal. 
Perhaps it should also be added, at this 
point, that burn toxemia does not charac- 
teristically lead to a nephritis; albumin- 
uria, though usually present, is probably 
only incidental to blood concentration, the 
kidneys being able only imperfectly to 
function under such conditions, though 
when the concentration is overcome they 
function again in a perfectly normal 
manner. 

Various observers, notably Underhill 
and Robertson and Boyd, have reported 
disturbances of protein metabolism as evi- 
denced by high non-protein nitrogen and 
urea blood values; the disturbance noted 
here is usually not particularly striking 
and can possibly be explained on the basis 
of blood concentration. 

Underhill has made the very interesting 
contribution that blood chlorides are de- 
creased in all but minor burns, and that 


Cutting — The Treatment of Burns 


115 


the blood chloride decrease is associated 
with a decrease of urinary chloride output. 
He goes to some length to show that this 
phenomenon cannot be explained on any 
ordinary grounds, such as diet, fever, vom- 
iting, alkali therapy, altered renal thres- 
hold, blood concentration, or transudation 
at the site of burn, but rather that it is in 
all probability a prptective phenomenon. 
The sodium chloride is stored in the 
tissues where it can be made to serve the 
purpose of combining with the primary 
toxic materials elaborated by the burned 
area before there has been an opportunity 
for the latter to produce damage. He 
thinks this is analogous to chloride reten- 
tion in pneumonia, and makes the obser- 
vation that just as in pneumonia, after the 
crisis, there is a large chloride elimination 
in the urine, just so in burns there is a 
readjustment of chlorides with marked 
urinary excretion following the separation 
of burn sloughs. He also quotes Hayden 
and Orr’s observation of chloride retention 
in intestinal obstruction as another ex- 
ample of a similar mechanism. 

PROGNOSIS. 

As to life, considering the moderately 
deep burns, the prognosis is probably 
favorable, other things being qual, in cases 
where less than 1/10 of the total body sur- 
face is involved, guarded where 1/3 or more 
has been burned, and grave where 2/3 is 
affected. This is, however, only the most 
general sort of an estimate, bums about 
the head, neck and shoulders being more 
dangerous to life than similar ones on the 
extremities, children being much less re- 
sistant than adults, and much depending, 
in any case, upon the general bodily 
resistance of the patient and the institu- 
tion of proper treatment. 

As to scar-formation and contracture 
deformities, deep burns have a relatively 
unfavorable prognosis, but much can be 
accomplished by early skin-grafting, the 
prevention of serious infection, and other 
therapeutic measures. 


TREATMENT. 

The question of prophylactic treatment 
is a large one, far too ponderous for a dis- 
cussion such as this, and it must be 
dismissed with the single suggestion that 
the crux is (1) education as to burn 
hazards, on the one hand, and (2) active 
protection for those constantly exposed to 
unusual hazards, on the other, especially 
those who, either due to lack of intelli- 
gence or the presence of organic lesions 
are particularly exposed to danger, specifi- 
cally the young, the insane, and the locally 
or generally anesthetic. 

There should be no routine treatment for 
burns. Rational therapy here, as else- 
where in medicine, depends upon individ- 
ualization of the case, a clear understand- 
ing of the pathology present in the specific 
instance being the indication now for one 
modification and now another. 

First degree burns, i. e., those character- 
ized by erythema without vesication, if 
they be of no considerable extent, produce 
no systemic reaction of moment and, indeed, 
cases developing them often do not seek 
medical aid. For such cases as do call for 
treatment picric acid, either in aqueous 
solution or as an ointment probably best 
meets the indications, it being at the same 
time both slightly anesthetic and anti- 
septic. 

Second degree burns and mild third de- 
gree burns, i. e., those in which scarring is 
not expected to be extensive, may be 
grouped together; according to their ex- 
tent they may be mild, severe, or very 
severe ; it must be constantly borne in mind 
that children bear burns poorly. The 
treatment should begin immediately after 
the patient is seen, and obviously the first 
indication is to prevent the further or con- 
tinued action of the exciting cause. Usually 
in cases where clothing has caught fire re- 
sulting in a bum the flame will have been 
extinguished before the patient is seen, but 
it is not an incident of very great rarity 
to see patients rushed in excitement into 
hospitals with their clothing still smoulder- 


116 


Cutting — The Treatment of Burins 


ing. On the other hand, where chemical 
burns are concerned the caustic will not 
usually have completely ceased to act at 
the time the patient comes under observa- 
tion; no time should be lost in preventing 
the possibility of further chemical de- 
struction. Davidson has gone to some 
length in determining the proper procedure 
in the case of the acid and alkali burns, 
and he has come to the conclusion as the 
result of carefully controlled animal expe- 
rimentation that dilution of these particu- 
lar caustic agents with quantities of water 
gives decidedly better results than any 
immediate attempt to neutralize them, base 
with acid and acid with base. 

Patients with extensive burns will 
usually be found in a greater or less de- 
gree of shock, burns about the face, neck, 
and shoulders being particularly prone to 
produce this condition. The exact mechan- 
ism of burn shock is not well understood; 
it is presumably caused by an overwhelm- 
ingly violent stimulation of sensory nerves, 
and individual idiosyncrasies are consider- 
able, some patients being prostrated by 
relatively mild trauma, and vice-versa. At 
all events shock is easily recognized by its 
symptoms, sub-normal temperature, rapid, 
running pulse, low systolic blood-pressure, 
and, in the more severe cases, cold clammy 
skin and coma or only partial conscious- 
ness. However severe the local lesion, to 
attempt its active treatment with a patient 
in shock is to jeopardize the patient’s 
chances of recovery by overlooking, medi- 
cally, the forest for the trees. The indica- 
tions here are to protect the burned area 
from infection and mechanical trauma by 
sterile dressings if possible, but clean 
sheets or the like will do otherwise, and get 
the patient immediately to some place 
where he can be kept w'arm, be provided 
with an abundance of fluids, by mouth, 
proctoclysis or hypodermoclysis, according 
to the needs of the case. He should be given 
morphin in sufficient amounts and suffi- 
ciently frequently to relieve him of his pain 
and keep him quiet. The treatment of 
the local lesion begins only when reaction 


from shock has definitely set in; milder 
cases of burns can, of course, be attacked 
locally without delay. The indications for 
local treatment are, in addition to those 
already mentioned, i. e., protection from 
infection and further trauma, (1) provis- 
ion for taking care of the copious exudate 
which may be expected from the burned 
area, (2) the relief of local pain, (3) the 
favoring of rapid granulation, and (4) 
whatever can be done to forestall the ab- 
sorption of toxins from the burned area 
into the blood stream. 

The clothing should be cut away, soaked 
away in water, or otherwise removed in 
such manner as will add as little trauma 
as possible to that already existing; gaso- 
line is often useful in cleaning up badly 
contaminated areas, since it is fairly 
grateful to the painful lesion and at the 
same time somewhat antiseptic. At various 
times debridement has been put forward as 
being indicated following the preliminary 
toilet, as, for instance, by Brager, Lieber, 
and Willis; for this purpose, the patient 
being placed under a general anesthetic 
and the traumatized tissue being either cut 
away or completely scrubbed away; this 
treatment is perhaps of value in certain 
unusual cases, but routinely, while it meets 
the indications for local treatment as given 
above in an ideal manner, it carries with 
it two side effects which usually negative 
its more obvious advantages, (1) the first 
is that it adds operative shock to that of 
the burn, (2) the second that in extensive 
burns, i. e., those involving considerable 
areas of the body, the added probability of 
scar-tissue formation and subsequent de- 
formity following operative trauma prob- 
ably rarely justifies the procedure. 

One of the favorite older methods of 
treatment was to cover the lesions with 
gauze compresses wrung out of mild anti- 
septic solutions in an attempt to keep the 
wound sterile; this method favors exuda- 
tion from the burned areas, fails to pre- 
vent the absorption of toxins, often suc- 
ceeds only in providing a warm moist 


Cutting — The Treatment of Burns 


117 


nidus for the development of bacteria, 
more frequently still provides extra 
trauma by repeated dressings, and almost 
always fails to make the .patient comfort- 
able. The addition of novocain solution to 
these dressings has been advocated to con- 
trol pain. As a result of the late war the 
method of spraying the burned area with 
some preparation of paraffin came to the 
fore ; in civil life various proprietary prep- 
arations containing paraffin as a base have 
been used, and while they usually do suc- 
ceed in making the patient ultimately 
comfortable often added temporarily to his 
discomfort by the heat used in melting the 
preparation, run the danger of developing 
a severe infection under the paraffin coat- 
ing, and inevitably failed to prevent the 
absorption of toxins and the exudation of 
fluid. 

In 1925 Davidson proposed the so-called 
“tannic acid treatment” of burns which 
seems to be such a distinct therapeutic 
advance over previous methods that any 
further recital of the many modifications 
of the above mentioned types may be 
omitted. 

The tannic acid treatment is proposed to 
fulfill the indications for local treatment as 
indicated above in a satisfactory manner; 
tannic acid has only a slight and unimpor- 
tant effect on the unbroken skin, but it 
precipitates proteins which are exposed 
directly to its action. Burned areas, which 
have become devitalized and are treated 
with tannic acid, are, accordingly, made the 
site of a coagulation process; this coagula- 
tion process or tanning prevents the spread 
of toxins generated in the diseased tissue 
and at the same time makes a coat- 
ing which protects the sensitive nerve 
ends in the undestroyed tissues from air, 
and from trauma. This coating also, being 
impervious to moisture, prevents the ex- 
travasation of tissue fluids, which is of 
obvious advantage in that it does away 
with excess loss of tissue fluids. 

In practice the tannic acid treatment 
consists of the application to the burned 


area, after removing gross contaminations, 
puncturing and cutting away blebs, and 
washing the surface gently with distilled 
water, of a freshly made solution of tannic 
acid in sterile distilled water, the recom- 
mended percentage strength varying from 
0.75 per cent to 5.0 per cent, a 2.5 per cent 
solution being perhaps advisable in the 
average case. The method of application is 
best by means of the spray or atomizer, 
in which case tanning of the involved area 
is slightly more rapid than when under- 
taken in other ways. Sterile gauze com- 
presses may be bandaged over the involved 
areas, these being subsequently wet with 
the solution by pouring the latter over 
them; it is simpler still to wet the com- 
presses and apply them wet, bandaging 
them securely afterward. If the spray is 
used the aim should be to repeat the pro- 
cess sufficiently often to keep the surface 
wet with the solution, i. e., every half hour, 
and if the wet compress method is used 
the compresses should be resaturated from 
time to time. The process of tanning 
should be watched, compresses being loos- 
ened and raised for the purpose every six 
hours, and as soon as the burned areas 
have assumed a uniform mahogany brown 
color the dressings may be removed or the 
spray discontinued. Complete tanning will 
usually take twenty-four hours or more with 
the compress method and sixteen hours 
with the spray. It should be emphasized 
that only fresh solutions of tannic acid 
should be used, for, while the dry powder 
keeps indefinitely, a solution of tannic acid 
rapidly becomes converted into the unsuit- 
able gallic acid. To avoid trauma incident 
to the removal of dressings at the end of 
the tanning period the latter should be 
allowed to become thoroughly wet with the 
solution just prior to their removal. Subse- 
quent to the tanning process the burned 
areas are left exposed to the air under a 
suitable tent which is covered with a 
sterile sheet to protect the wounds from 
contamination and within which are placed 
a number of electric light bulbs sufficient 
to keep the temperature within at an even 


118 


Cutting — The Treatment of Burns 


100° F. The tanned areas become grad- 
ually dry as a result of the exposure to 
the warm air, the interval necessary to 
complete the process being not less than 
another twenty-four hours and sometimes 
several times as long, depending mostly on 
the depth of the burn. A. 5 per cent ointment 
of tannic acid in a base composed of equal 
parts of lanolin and petrolatum has been 
advocated in lesions situated about the 
eyes, ears, and similar orifices where the 
use of an aqueous solution on compresses 
may be unsuitable ; with due care the spray 
may be used, however, in these locations 
and it is much superior for the purpose. 

When properly tanned and dried the sur- 
face of the lesion is found to be covered by 
a tough, dark brown, leathery membrane 
which is insensitive to pain, which forms 
an almost ideal protection from trauma, 
and which seems clinically to interfere in 
no way with the subsequent granulation of 
the wound from below; in fact, the con- 
trary represents the case more correctly 
because healing is usually relatively rapid 
and very satisfactory. 

The local treatment being started, in one 
way or another, preferably by the method 
just suggested, the systemic treatment is 
continued. Barring shock, which is early, 
patients die from blood concentration, 
toxemia, or infection; the indications are, 
accordingly, (1) to force fluids early, 
(2) to recognize toxemia if it occurs in 
spite of local treatment, and treat it intel- 
ligently, and (3) to recognize the presence 
of infection and attempt to control it. 

Fluids should be given early and in fairly 
large quantities ; usually the patient, if not 
too severely burned, will co-operate by 
taking quantities of fluids by mouth, but 
otherwise proctoclysis is invoked, or even 
hypodermoclysis in cases where other 
methods do not sufficiently avail. 

Toxemia, which may be expected to 
ensue not earlier than 8 hours after a 
burn and to disappear in from three to five 
days can be combatted specifically by no 


known method. The prophylactic use of 
blood transfusion in severe cases of 
burns should be considered early; its 
efficacy probably varies largely in inverse 
ratio to the interval elapsing before it is 
invoked. If Davidson is right in his con- 
tention that sodium chloride combats the 
toxemia by neutralizing or fixing the 
toxins before they have had an oppor- 
tunity to exert a minimum effect, frequent 
chloride determinations on the blood of the 
patients are of the utmost importance, to 
be accompanied by the administration of 
sufficient sodium chloride to keep up a nor- 
mal concentration. It must be urged that 
Davidson is of the opinion that the best 
available index of the patient’s condition is 
to be derived by the determination of his 
blood chloride content. If Greenwald and 
Eliasberg’s contention is correct that the 
toxin, once formed, attacks primarily the 
adrenal glands, first stimulating them to 
the excess production of adrenalin and 
then later damaging them to the ex- 
tent that a marked reduction of the 
sugar level is produced, adrenalin should 
be supplied hypodermically after the elapse 
of a sufficient time to allow the initial 
stimulating effect of the toxemia to have 
passed off. At any rate the blood sugar 
should be estimated frequently in burn 
cases, since we know that in certain of 
them the sugar values are low, and in these 
the administration of glucose, with or 
without insulin should be of value. 
Frequent hemoglobin estimations are a 
measure of the blood concentration ; the 
prophylactic treatment of this condition is 
far more easy than the overcoming of it 
after it is once established. 

The treatment of infection is mainly 
prophylactic. A burn is always a poten- 
tially infected wound, and few, if any, 
escape pus production entirely. When pus 
does form, especially if paraffin or tannic 
acid has been used, drainage should be 
established by cutting away the paraffin 
coating or the tanned area, as the case may 
be; this being facilitated in the latter in- 


Cutting — The Treatment of Buriw 


119 


stance "by softening the membrane first 
with liquid petrolatum. 

Deeper third degree hums. The deeper 
third degree burns which forbode exten- 
sive scar formation often tax the resources 
of the surgeon to the limit as far as the 
prevention of the latter complication is 
concerned; otherwise the treatment is both 
local and general as indicated for any 
severe burn. The thick protective mem- 
brane which results from a properly pro- 
duced tanning by the method of Davidson 
often facilitates early skin grafting in two 
ways: (1) It affords a dry protective 
splint in which the patient can lie fairly 
comfortably while waiting for skin grafts 
to “take” on the opposite side of the body, 
and (2) the bed left by the removal of the 
membrane is particularly suitable for 
grafting. The early institution of move- 
ments designed to prevent contracture de- 
formities especially in localities which are 
liable to fusp together is of particular 
importance. 

CONCLUSION. 

The treatment of burns is now sufficiently 
well developed along rational lines to stim- 
ulate the surgeon’s most active interest in 
his burn cases; the field for research is 
large and the rewards for careful treat- 
ment in this field are as great as can be 
found anywhere. 

BIBLIOGRAPHY. 

Bancroft, F. W. & Rogers, C. S. : Treatment of cutane- 
ous burns. Ann. Surg., 84:1-18, 1926. 

Beck, C. S. & Powers, J. H. : Burns treated by tannic 
acid. Ann. Surg., 84:19-36, 1926. 

Behrend, M.: Contractures due to burns of face, neck 
and body. Surg. Clin. N. Amer., 6:237-243, 1926. 

Cabot case 12,184: Problem in surgery of traumatic 

(burned) hands. Bost. Med. & Sur. Jour., 194:848-849, 
1926. 

Colgin, I. E. : Burns, Texas State Jour. Med., 21:668-670, 

1926. 

Davidson. E. C. : Treatment of acid and alkali burns. 
Ann Surg., 85:481-489, 1927. 

Davidson, E. C. : Sodium chloride metabolism in cutaneous 
burns and its possible significance for a rational therapy. 
Arch. Surg., 13:262-277, 1926. 

Goldblatt, D. : Study of burns, their classification and 
treatment. Ann. Surg., 85:490-501, 1927. 


Greenwald, H. M. & Eliasberg, H. : Pathogenesis of death 
from burns. A. J. M. Sci., 171 :682-96, 1926. 

Moorhead, J. J., & Killian, J. A.: Metabolism in burns. 

Bull. N. Y. Acad. Med., 3:401-409, 1927. 

Pack, G. T. : Etiology and incidence of thermal burns. 

A. J. Surg., 1:21-25, 1926. 

Ravdin, I. S. : Treatment of superficial burns. Surg. 

Clinics N. Amer.. 6:1579-1583, 1925. 

Trueblood, D. V. : Paraffin treatment for burns and 

denuded areas. Northwest Med., 25:255-258, 1926. 

Underhill, F. P.: Changes in blood concentration with 

special reference to treatment of extensive superficial burns. 
Ann. Surg., 86:840-849, 1927. 

DISCUSSION. 

Dr. Isidore Cohn (New Orleans) : The first 

thing expected, and this time well merited, is to 
say that we have all enjoyed and appreciated Dr. 
Cutting’s splendid presentation. He has brought 
home very forcibly to us the importance of the 
toxic condition due to the absorption of the burned 
products of the body and the principles underly- 
ing the treatment of this as brought out by Da- 
vison: first, the necessity of preventing the ab- 

sorption of these autolytic products, which can 
be done in many ways, most of which he has 
called our attention to. But from a practical 
standpoint there are certain fundamental things 
we ought to keep in mind, viz: 

1. To relieve pain, and by relieving pain pre- 
vent the further development of shock. 

2. Maintain body fluids as far as possible. 
Just because patient has a burn is no reason why 
they should not get fluids by every possible 
means; proctoclysis, hypodermoclysis and even 
transfusion. 

3. The question of preventing absorption of 
burned products is of fundamental importance. 
Tannic acid seems to do this about as well as 
any agent we have, because it produces local 
coagulation. 

4. Prevent contracture. I was very much 
amused a few years ago by an article entitled 
The Orthopedic Treatment of Burns, the author 
having in mind the prevention of contracture. 
This can be prevented in the early stages by mak- 
ing that patient move his fingers and joints as 
much as possible. 

Keep these things in mind and there is no 
reason why our patients should not do well. 

Another thing he refers to are the changes 
which give us the impression of a definite nephri- 
tis, definite as far as the presence in the urine of 
albumin, casts, a certain amount of blood, etc., is 
concerned. This is a transient condition. Later, 
however, all traces of the preceding toxic nephritis 
disappear. 


120 


Alsobrook — Interstitial Pregnancy Unruptured 


Dr. R. A. Cutting (closing) : I wish to thank 
Dr. Cohn for his discussion and to express my 
regret that it was necessary to delete freely and 
read rapidly in order to keep the paper within the 
time limit pointed. out by your chairman earlier in 
the evening. 

With respect to the orthopedic treatment of 
contractures following burns there is in the 
Clinics of North America for February, 1926, 
a report of a series of plastic operations on a 
male, aged 5 years, burned while playing with 
matches. The report is of interest because of the 
seriousness of the deformity resulting from burns 
over the anterior neck and chest in this case, the 
chin being bound down to the sternum by scar 
tissue so dense that the chin could not be palpated 
through it nor could the patient close the mouth 
or lips nor masticate food. 


INTERSTITIAL PREGNANCY 
UNRUPTURED; 

WITH REPORT OF CASE. 

H. B. ALSOBROOK, M. D., 

New Orleans. 

Interstitial pregnancy refers to that type 
of case in which the ovum develops in 
that portion of the tube which passes 
through the wall of the uterus or in a 
diverticulum from that part of the tube or 
in an accessory tube. 

HISTORY. 

Several authors have given Pierre 
Dionis credit for being the first to describe 
a case of interstitial pregnancy, published 
in 1718. Mauriceau claimed one case be- 
fore this. Schmidt (1801) is generally 
credited with having the first authentic 
case. Mayer (1825) published a treatise 
on this subject with four cases. Brechet 
reported cases in 1826. 

The first cases reported by an American 
were by R. H. Fitz of Boston, in 1875, 
when he reported eighteen cases. 

FREQUENCY. 

The interesting features of interstitial 
pregnancy are its relative infrequency and 
its difficult diagnosis. It' is the rarest of 

*Read before Orleans PaHsh Medical Society, 
March 12, 1928. ' - . 


ectopic gestation with the exception of 
ovarian and some authorities do not believe 
the ovarian type exists. Pfaff believes in- 
terstitial pregnancy more frequent than is 
believed. 

Lawson Tait, in commenting upon a 
post-mortem specimen, wrote: “In the 

enormous experiences I have had of tubal 
pregnancy this is my solitary experience 
of interstitial tubal pregnancy, but it so 
closely resembles a number of which I have 
seen in museums, that I take it to be quite 
typical of its class. I am, therefore, dis- 
posed to believe, from physical examina- 
tion, that interstitial pregnancy could not 
be diagnosticated, and I can imagine no 
symptom which would help us to recognize 
it before rupture.” He found only six 
specimens in the English Museum up to 
1890. 

Rosenthal reported thirteen hundred and 
twenty-four ectopic pregnancies before 
1896, the interstitial type occurred in 3 per 
cent. Munro-Kerr reported one case in 
eighty or 1.25 per cent. Lequex reported 
seventy-five cases up to 1911. Levy re- 
ported twenty-six cases collected from 
literature from 1918 to il925. Martin and 
Orhman, one in fifty-seven cases. Wynne 
reported fifteen hundred and forty-seven 
cases of ectopic pregnancy, of which 1.16 
per cent were interstitial. Farrar reported 
three in three hundred and nine cases of 
ectopic. From Touro Infirmary two were 
reported in forty-five cases. At Charity 
Hospital, over a period of twelve yeafs, 
three hundred twenty-seven cases, only one 
could be claimed as interstitial with two 
others as doubtful. 

ETIOLOGY. 

It is agreed that salpingitis-oophoritis, 
pelvic adhesions, infantile tubes with lack 
of cilia, diverticula and accessory tubes 
are the predisposing causes of interstitial 
pregnancy as well as tubal pregnancy. 
Mall, in one hundred seventeen cases of 
tubal pregnancy collected over a period of 
seventeen years, stressed the inflammatory 
changes which must have preceded the 


Alsobrook — Interstitial Pregnancy Unruptured 


121 


lodgement of the ovum in the tube. Farrar 
does not believe that inflammatory changes 
play such an important part in causing in- 
terstitial pregnancies as in true tubal 
pregnancy. She stresses the mechanical 
obstructions, such as the uterine orifice in 
the tube, or an adenoma at the angle of the 
tube or at the junction of the tube and the 
uterine cavity. She also mentioned con- 
genital malformations, as accessory tube 
or diverticulae. Levy suggested that pos- 
sibly infantilism of the female genitalia, 
with a very small lumen of the tube caus- 
ing the arrest of the ovum in the intersti- 
tial portion. Michinard brought out the 
fact that in most cases of tubal gestation 
the ovum is arrested some distance from 
the fimbriated end of the tube and as it re- 
quires some seven days for the impreg- 
nated ovum to travel through the oviduct, 
the ovum may develop and wedge in a nar- 
rowed part of the tube. Frankl considers 
the presence of diverticula of utmost im- 
portance as a cause. Donald McIntyre re- 
ports a case of interstitial pregnancy in the 
right side of the uterus two and one-half 
years after a salpingo-oophorectomy was 
performed on the same side for an inflam- 
matory condition of the tube and ovary. 

CLASSIFICATION. 

The classification and differentiations of 
interstitial pregnancy have been thor- 
oughly discussed by Weinbrauer, Kohlman 
and Lequex. The implantation of the ovum 
must be in the interstitial portion of the 
tube including diverticula from the tube, 
extending into the uterine muscle. But in 
view of the fact that the development of 
the embryo may change anatomical rela- 
tions to some extent, various classifications 
have been proposed, but that of Klebs 
divides interstitial pregnancy into three 
groups according to the location of the im- 
bedding site as found at operation : 

1. Utero-interstitial pregnancy, when 
the ovum occupied the uterine end of the 
cornual canal. 

2. Tubo-interstitial pregnancy, when 
the ovum occupied the tubal end of the 
cornual canal. 


3. Interstitial pregnancy proper, when 
the ovum is imbedded about the middle of 
the cornual canal. 

However, Litzenberg believes the classi- 
fication of Erna Glaesmer much simpler 
but quite adequate: 

1. The ovum develops in the fundus 
musculature of the uterus. 

2. The development occurs in the side 
wall of the uterus. 

3. The development occurs toward the 
isthmus of the tube. 

PATHOLOGY. 

Litzenberg, in his anatomical and his- 
tological report of a case, summarized the 
pathology as follows: 

“Interstitial pregnancy differs from 
other types of ectopic gestation only as 
the peculiar anatomical conditions which 
surrounds it may modify its progress; the 
course and structure of the Intra-mural 
tube leads to implantation near the pos- 
terior wall of the fundus. The structure 
of the tube and the uterine wall favor early 
rupture of the tube and late rupture of the 
ovum capsule otherwise interstitial preg- 
nancy repeats most of the features of 
ectopic gestation elsewhere.” 

DIAGNOSIS 

The signs and symptoms of an intersti- 
tial pregnancy are those of ectopic preg- 
nancy. However, the pain is usually early 
and as Schuman states, usually develops 
before bleeding or death of the ovum takes 
place. This is due to the distention of the 
uterine horn, which does not distend 
readily. Lewers considers persistent amen- 
orrhea a very important sign in differen- 
tial diagnosis. Wynne reported amenor- 
rhea in twelve or thirty-six of the cases, 
the period regular in two, irregular in 
twenty-two but slight in five of these. In 
my case the pain and bleeding appeared 
simultaneously. This case is the only one 
that I have found in the literature that had 
repeated chills and fever. The diagnosis 
before rupture depends upon vaginal ex- 


122 


Alsobrook — Interstitial Pregnancy Unrtiptured 


amination, a fairly regular enlargement 
extending around one cornu of the uterus 
with a broad base upon the uterus and an 
absolute absence of a pedicle. The en- 
largement may be very firm from tension 
and give the impression of fibroid, but the 
history should rule out fibroid. It may be 
confused with one sided pelvic inflamma- 
tion of the tube, or an intra-uterine preg- 
nancy with ovarian cyst. Pregnancy in 
one born of a bicornuate uterus may pre- 
sent serious difficulty in making a differ- 
ential diagnosis, also unilateral corunal 
abscess. 

Virchow noted that the round ligament 
is always outside of the gestation sac. 
Ruge’s sign, as stated by Simon, is that 
the distance between the insertion of the 
tube and the round ligament is increased 
and the adenexa of the affected side are 
higher than on the other side, owing to the 
increase in the size of the pregnant horn 
and some rotation of the uterus following 
this symmetrical development. A positive 
diagnosis of interstitial pregnancy, before 
operation is very unlikely, but careful his- 
tory, watching and examination under 
an anesthetic will often clear up the 
diagnosis. 

PROGNOSIS. 

Twenty-one unruptured interstitial preg- 
nancies out of ninety-one have been re- 
ported up to 1917, or 23 per cent. The 
termination is usually a sudden profuse 
intraperitoneal hemorrhage — this is due to 
the vascularity at the cornu of the uterus 
and as the hemorrhage is profuse, clots 
and adhesions do not have time to form. 
Beckman and Seifart believes that perfor- 
ations always occur on the posterior con- 
vex surface of the gestation sac. Wynne 
reported eight out of twenty on the pos- 
terior surface, five on the posterior supe- 
rior surface, one on the posterior lateral, 
three on the superior, two on the superior 
anterior and one on the anterior surface 
of the sac. The pregnancy usually ter- 
minates in two or three months and if the 
patient does not die of shock or hemor- 
rhage a hematocele may develop. In the 


utero-interstitial type it may abort into the 
uterine cavity and go on to term, or a mole 
may form. It has been reported to de- 
velop to maturity in the broad ligament or 
as an abdominal pregnancy. Kupferberg 
reported a case in which an eight month 
fetus was found. Glaesmer reported a 
seven months. Seifart claims no intersti- 
tial pregnancies are seen after six months. 
Williams reported one rupture after four 
months. Pfaff reported one after five 
months — unruptured. Louis Mcllroy in 
1926 reported a case at term. Wynne 
gives the mortality as 11.0 per cent, Fin- 
isterer gives 10.4 per cent, Shink 22.2 per 
cent. Prior to 1893, all the cases in litera- 
ture had been found at autopsy. 

TREATMENT. 

The treatment is always surgical, 
whether ruptured or not. The first oper- 
ation for interstitial pregnancy was by 
Traub, October 115, 1893, who did supra- 
vaginal hysterectomy. Seven days later, on 
October 23, 1893, Lawson Tait operated on 
a case by incising the sac, evacuating the 
contents and draining. If diagnosis is made 
before rupture laporotomy should be per- 
formed if the condition warrants. If rup- 
ture has occurred immediate laporotomy is 
indicated. A great variety of operations 
have been done for this condition but the 
type of operation should be selected to fit 
the emergency. Supravaginal hysterec- 
tomy is usually preferred, but excision of 
the cornum may be done in young women 
if the condition warrants. The abdominal 
route is undoubtedly the best. Speed and 
team work are always to be considered. 
Blood transfusions, saline and glucose in- 
fusions are always in order. 

CASE REPORT. 

L. J., a colored female, aged 35 years, married 
for fourteen years and a housekeeper by occupa- 
tion, was first seen September 20, 1927. At this 
time she was complaining of chills and fever, pain 
in the right side of her abdomen and loss of blood 
for one month. The family history was negative. 
She had had the usual diseases of childhood. She 
had had influenza in 1918, and no other serious 
illnesses There was no history of pelvic inflam- 
matory disease. Menstrual History: Menses be- 


Alsobrook — Interstitial Pregnancy Unruptured 


123 



Fig, 1 — Cross section. A — Sac, 


B — Umbilical cord. C — Endometrium. D — Uterine Cavity, 


124 


Alsobrook — Interstitial Pregnancy Unruptured 


gan at the age of 11 years, regular 28-day type, 
lasting four to five days with a normal flow. 
(They were regular until May, 1927, when she 
skipped May, June and July.) There had been 
no pregnancies nor miscarriages. The last menses 
stopped September 10. Present Illness: The last 

menstrual period ended April, 1927. At this time 
she had slight morning nausea and thought she 
was pregnant. About the middle of August she 
began menstruating, which was accompanied by 
sharp lancinating pain in the right side of the ab- 
domen. She passed clots and lost much blood. 
Ten days later she began having hard chills fol- 
lowed by high fever, lasting four or five days — 
recurring in five or six days. The patient took 
quinin for malaria. The last chill occurred about 
September 12. She was admitted to the hospital 
September 21. 

Physical Examination: The patient was fairly 

well developed but poorly nourished negress, 
height 5 feet 4 inches, weight 100, appearing 
acutely ill. The temperature was 103°F, pulse 
126, respiration 24, blood pressure, systolic 118, 
diastolic 90. The skin was warm, moist and elas- 
tic. A mass, apparently about four inches in diam- 
eter, was felt in the right lower quadrant of the 
abdomen, being extremely sensitive. Vaginal Ex- 
amination: The mucous membrane was purplish. 

There were no vaginal secretions. The vagina 
admited two fingers. The cervix was soft, not 
dilated. The uterus was soft, about the size of a 
large orange. A soft mass was felt attached to 
and extending from the right cornu of the uterus. 
This was very sensitive to the touch and freely 
movable. The left tube and ovary were appar- 
ently normal. Pre-operative Diagnosis: Tubal 

pregnancy — infected — unruptured. Laboratory 
and Pathological Reports: September 21, 1927. 

Urine, catheterized, negative except few leuko- 
cytes. Wassermann negative. P.S.T. test: first 
hour 40, second hour 40. Blood examination 
showed total 18,700 white cells, differential leuko- 
cytes: Neutrophils 91 per cent, large mononuclears 
6 per cent, lymphocytes 3 per cent, no malaria 
plasmodia found, anisocytosis, poikilocytosis and 
polychromtophilia. September 27, 1927. Urine 
catheterized, trace albumin, trace sugar, acetone 
positive four plus, occasional fine granular cast, 
slight deposit of pus, occasional red blood cell. 
Blood count practically same as September 21, 
1927. October 3, 1927. Spinal fluid: Wasser- 
mann reaction negative, cell count 1, globulin re- 
action a trace. 

Gross Specimen: Upon sectioning the uterus 

its wall was found to be markedly thickened and 
the endometrium was flattened. Upon opening the 
fluctuating mass a fetus, apparently of four 
months impregnation was found. It was normally 
formed and measured from the vertex of the skull 


to the tip of the spine (Minot line), 3% inches. 
The sac was found to be lying in the wall of the 
uterus entirely free from the uterine cavity. 

Microscopic: Uterus — interstitial pregnancy 

with marked hyperplasia of uterine wall. Tubes 
— chronic salpingitis. Ovaries — healed corpus 

lutein cysts. Appendix- — chronic appendicitis. 

Progress notes: September 21, 1927. Admit- 

ted at 9:10 a.m. Walked in. Temperature 103.4°, 
pulse 126, respiration 24. Had chill during night. 
Treated symptomatically. Operation postponed. 
September 22, 1927. Hard chill at 6 p. m. Tem- 
perature 104°. Lancinating pains in right side of 
abdomen. No further complaint. Prepared for 
operation. Postponed. September 27, 1927. 

Slight chill at 8 a. m. Hard chill at 5:30 p. m. 
Temperature 104°. Operation postponed. Com- 
fortable until September 29. Chilly sensation. 
Temperature 103°F. Complaining of slight soi’e 
throat. Throat red, no tonsillitis. Treated symp- 
tomatically. October 1, 1927. Complaining of 
pain in right side of abdomen. Mass apparently 
growing larger. October 3, 1927. Day of opera- 
tion. Temperature morning of operation 101°, 
pulse 124, respiration 24. 

Post-operative notes: Maximum, temperature 

99.6°, pulse 108, respiration 22. Uneventful re- 
covery. Incision healed by primary union. No 
tenderness. Discharged October 13, 1927. Jan- 
uary 15, 1928, feeling fine, gaining weight. 

Pre-operative Preparation: October 2, 1927. 

Prepared for operation. Pre-operative sedative 
of luminal grs. 2 at 8:45 p. m. October 3, 1927. 
Pantopone, grs. 1/3 at 6:45 a. m. Morphin sul- 
phate, grs. 1/6 and atropin sulphate, grs. 1/150 
at 7:15 a. m. Adrenalin chloride 1 1000 mms. 15, 
at 8:15 a. m. 

Operative Procedure : In a sitting position the 

skin of the back was prepared with benzin-iodin 
and iodin. One and one-half grains of apothesine 
in three centimeters of normal saline was injected 
between the first and second lumbar vertebrae. 
In the Trendeleberg position tne skin was prepared 
as before. The abdomen was opened through a 
midline incision, five inches long, between the um- 
bilicus and symphysis pubis. The upper abdomen 
was packed off and Balfore retractors placed. No 
free fluid was found in the abdomen. The uterus 
and tumor mass was free from adhesions and was 
drawn into the incision. The uterus was soft, the 
size of a large orange and extending from the 
right cornu was a mass about 3 inches long by 
2 V 2 inches wide. The right tube was stretched 
over the mass but the round ligament was an- 
terior and inferior to the mass but higher than 
the one on left. The blood vessels were dilated 
and markedly congested. The mass was of a blu- 


Alsobrook — Interstitial Pregnancy Unruptured 


125 



Fig. 2 — 1 — Membranes. 2 — Umbilical cord. 3 — Fallopian 
tube. 4 — Endometrium. 


ish color, soft and evidently contained fluid. Con- 
sidering the patient’s age, a supravaginal hyster- 
ectomy was done, including both tubes and ovar- 
ies. The round ligaments were sutured to the 
stump of the cervix and a nice peritoneal toilet 
was accomplished. The appendix was free, about 
two inches long, pale, evidently in stage of chronic 
inflammation. It was removed with double liga- 
ture of chromic catgut No. 3 and cautery. The 
abdomen was closed in tiers with single No. 3 
chromic. Silk worm was used for retention su- 
tures and dermal for the skin. Analgesia was com- 
plete and there was no nausea. 

CONCLUSIONS. 

1. Infection or mechanical alteration in 
the interstitial portion of the tube predis- 
pose to interstitial pregnancy. 


2. Early diagnosis and immediate lap- 
orotomy are imperative. 

3. Supra-vaginal hysterectomy is the 
operation of choice. 

BIBLIOGRAPHY. 

1. Farrar, L. K.P. : Analysis of 309 cases of ectopic 

gestations in the woman’s hospital in state of N. Y. Amer- 
Jour. Obst. and Dis. Women and Children, 79 :733, 1919, 

2. Nelson, H. M. : Unruptured interstitial pregnancy. 

Amer. Jour. Surg., 3:271, 1927. 

3. Levy, W. E. ; Interstitial pregnancy with the re- 
port of unruptured case. Amer. Jour. Obst. and Gyn. 
9:93-100, 1925. 

4. Pfaff, O. G. : A case of interstitial tubal pregnancy. 

Amer. Jour. Obst. and Dis. of Women and Children, 79:106, 
1919. 

5. Wynne, H. M. N. : Interstitial pregnancy. Bui. Johns 

Hopkins Hosp., 29:29, 1918. 

6. Litzenberg, J. C. : Unruptured interstitial pregnancy, 

with anatomic and histologic report of an early case. Amer. 
Jour. Obst. and Gyn., 9:22-34, 1925. 

7. Musselman, Luther: Amer. Jour. Obst. and Gyn., 

13:23, 1927. 

8. Graffagnia, P. : Amer. Jour. Obst. and Gyn., 4:148- 

54, 1922. 

9. Hall, F. P.: Surg, Gyn. and Obst., 21:289-93, 1915. 

10. Text Books. Williams’ Obstetrics, 1917. DeLee 
Obstetrics, 1925. Shears’ Obstetrics, 1924. Graves’ Gyne- 
cology, 1923. 

DISCUSSION. 

Dr. H. W. Kostmayer (New Orleans) : The 

pleasure that I took in accepting Dr. Alsobrook’s 
invitation to open the discussion was somewhat 
lessened by the reminder that it has been a great 
many years (too many years) since my first paper 
before the Society, which was on this very sub- 
ject — a case of extra-uterine pregnancy. It is 
evident, from this fact, that from the beginning 
I have been keenly interested in this subject with 
its many variations. 

The topic is interesting for two pronounced 
reasons; one is the phenomenon of the ovum be- 
ing able to develop outside of its normal habitat; 
the other is the extreme difficulty of diagnosis. 
It always seems to me a marvelous thing that an 
ovum, impregnated, intended to lodge in the uterus 
should take up its residence elsewhere and con- 
tinue to develop and even go to term (as in the 
cases of interstitial and abdominal pregnancy 
that do) and find a way of nourishing itself, at- 
taching itself to anything for blood supply and 
continuing, as I say, to full term. On the other 
hand, the diagnosis of extra-uterine pregnancy in 
any form is extremely difficult, so much so that 
we check ourselves in the service to ascertain 
how often our interpretations are correct, or the 
reverse obtains. We have a case come in with a 
typical history — missed menses, pain in one or 


126 


Maxwell — Treatment of Acne 


the other side of the abdomen, mass in one or 
the other side, — and put down a diagnosis of 100 
per cent extra-uterine pregnancy, and find an ovar- 
ian cyst. This happened to us just last week. 
Then again we have opened an abdomen without 
suspecting this condition, to find a ruptured extra- 
uterine pregnancy in which the bleeding had 
ceased. The diagnosis of interstitial pregnancy 
(by which is meant separating it from other types 
of ectopic gestation) is largely a matter of guess 
work. I would not assume that I could differenti- 
ate in these cases and state that an extra-uterine 
pregnancy was interstitial. It has been my mis- 
fortune to handle one case, the only one reported 
from Charity Hospital. This went to table as a 
diagnosis of extra-uterine without a thought of it 
being an interstitial pregnancy. 

I want to say that I enjoyed Dr. Alsobrook’s 
paper and his resume of this subject which makes 
it such a worth while study in that it brings to 
us all of the knowledge of the literature up to 
date. 

Dr. H. R. TJnsworth (New Orleans) : It is of 

interest that spinal anesthesia was used in this 
case. I do not remember hearing any particular 
indication as to why this method was used, but 
I feel it is to be regarded with a great, deal of 
respect, and unless there are very definite indi- 
cations for its employment I feel that it is not 
an anesthetic of choice. I should like to ask Dr. 
Alsobrook if there were any unusual post-opera- 
tive complications of bladder or rectum that he 
could in any way attribute to spinal anesthesia. 

Dr. Abe Mattes (New Orleans) : The employ- 

ment of spinal anesthesia in ectopic pregnancy is 
the method of choice in quite a number of cases 
that would not withstand some other procedure 
and at times the decided factor that makes for 
the well being and recovery of that patient after 
operation. 

Regarding the serious consequences that may 
follow its use in ectopic gestation, the danger is 
no greater than in other operations. I think spinal 
analgesia can be used with perfect safety, irre- 
spective of whether the patient is suffering from 
ectopic pregnancy or from any of the other oper- 
ative conditions we encounter. 

Dr. H. B. Alsobrook (closing) : In reply to 

Dr. Unsworth regarding the use of spinal anes- 
thesia in this case. In the first place she was a 
poor surgical risk, having bled continuously for 
one month before she came in. Secondly, she had 
a slight respiratory affection at the time of ad- 
mission and fearing that inhalation anesthesia 
might cause a recurrence of the condition, we 
considered spinal the anesthetic of choice. There 
was also some blood disturbance. As for naralytic 


ileus, I have only seen one case in the past three 
years in spinal anesthesia. My patient had no 
laxative other than milk of magnesia on the 
third day and voided voluntarily after eight 
hours. The maximum temperature was 99.6°, the 
pulse 124 on the evening of the operation. 

I wish to thank Drs. Kostmayer and Mattes for 
their discussions. 


TREATMENT OF ACNE. 

T. A. MAXWELL, M. D., 

New Orleans. 

In considering the treatment of any dis- 
ease one is forced to realize that one 
agent, no matter how skillfully employed, 
is not able to meet and eradicate all con- 
ditions which may arise. Without divid- 
ing acne conditions into their respective 
groups, I will attempt in this short paper 
to cover the practical treatment of this 
disorder in a general way. 

In the cases which give just the ordi- 
nary comedones with little or no signs of 
inflammation I believe that the roentgen- 
ray given in doses of one quarter skin unit 
once a week is sufficient. In explanation 
of this point it should be said that as soon 
as the lesions are retrogressive, by this I 
mean that the inflammation has subsided 
and no new sign of inflammation is occur- 
ring, is time to stop treatment with the 
roentgen-ray even if just three doses of 
one-quarter skin units have been used. 
Then the skin should be watched for a re- 
currence when further roentgenotherapy 
may be used. I believe in this way the 
smallest amount of roentgen-ray can be 
used and the best results attained. 

Another way to judge the results of 
treatment is by making use of the come- 
done extractor upon patients presenting 
themselves for treatment. There can be 
extracted one or more comedones approx- 
imating the length of the sebacous plug. 
After giving several treatments again ex- 
tract some of the plugs and it will be 


Maxwell — Treatment of Acne 


127 


found that the length is much shorter, 
proving, as I believe, the capacity and func- 
tion of the glands has been cut down; 
which after all is the cause of the condi- 
tion, the hyper-activity of the pilo-sebacous 
glands. 

In cases of pustular acne in which there 
are signs of secondary infection, I advise 
the use of roentgen-rays for two reasons: 
one that the activity of the glands being 
decreased and the amount of blood to 
these parts being diminished, the infection 
becomes less, the pustules dry up and heal- 
ing takes place, the crust being thrown off 
with very little scar resulting. In the 
second place, the pus from the pustules left 
in situ being absorbed, acts as an auto- 
vaccine for the patient. Pustules of larger 
caliber should be opened by the cataract 
knife and drained because they will cause 
necrosis of the skin and leave large un- 
sightly scars. 

Again in these cases I find it very suc- 
cessful to have the patient use a mask of 
several layers of gauze soaked in saturated 
solution of boracic acid, applied to the 
entire face for about four hours a day. 
This solution will take care of the miliary 
pustules which in some instances con- 
tinually recur. As far as the scars are 
concerned, especially those which take on a 
keloid character, roentgen-therapy makes 
them much smaller and the results are very 
gratifying. Naturally those deep scars 
which resemble the scars of small-pox can 
never be eradicated and are there to stay. 

Diet has little affect on the treatment 
either one way or the other. I allow my 
patients to partake of sweets freely or any 
other food which is claimed by others to 
affect the treatment and I have observed 
no difference in results. 


I do not believe that the general consti- 
tutional treatment plays a part in the 
treatment. All cases have their basic cause 
in the hyper-function of the pilo-sebacous 
glands and. the eradication of this condition 
produces the results. I have many times 
seen severe cases of acne in the healthiest 
individuals. 

The patients that complain of very few 
lesions on the face but extreme oiliness of 
the skin I take to be due to the hyper- 
function of the sebacous glands; the roent- 
gen-ray is most useful. The giving of one- 
quarter of a skin unit once a week for two 
or three doses will relieve this condition 
for as much as eight months or more. 
When recurrence takes place another treat- 
ment or two is all that is necessary. This 
method will take care of the oiliness and 
at the same time will give us a large mar- 
gin of safety as far as dosage is concerned. 
It does not cut down the oil too much, the 
result of which would be a parchment like 
skin, subject to any and all irritation. 

Before closing I wish to call attention 
to what I consider the most important 
phase in the treatment of acne. The scalp 
should be cleared of dandruff because these 
seborrheic scales fall on the face, irritate 
the mouth of the pilo-sebacous glands, 
causing an infection and necessarily a vir- 
tual closing of the lesions. With the stop- 
page of drainage and blocking of the secre- 
tions there is started a papule of acne, plus 
skin erythema, and the pustules then begin. 
I have entirely cleared up several cases of 
acne by merely keeping the scalp clean. 

In treating acne I would like to have one 
statement stand out very prominently: 
Clear the scalp in all cases; I have never 
seen a case of acne without dandruff. 


REVIEWS 


SURGERY OF THE RETICULO- 
ENDOTHELIAL SYSTEM.t 

ISIDORE COHN, M. D.,* 

New Orleans. 

The subject under consideration empha- 
sizes the need for closer co-operation 
between internist and surgeon, and the 
necessity for co-ordination of their clinical 
experience with the advancing knowledge 
gained by physiologists in their conquest of 
the fields of mystery. 

The reticulo-endothelial system, so named 
by Aschoff, consists of certain connective 
tissue cells both fixed and wandering 
found in the liver, (Kupffer cells), spleen, 
lymphatic system, bone marrow and the 
vascular net work of the omentum and 
mesenteries. 

Aschoff does not consider these cells of 
hematogenous origin. They are the great 
phagocytes of the body. “The reticulo-en- 
dothelial system must be considered the 
means of control of the cellular elements 
of the blood.” (Krumbharr.) The site of 
their greatest activity is in the spleen. 

Surgery of this system resolves itself 
almost entirely into surgery of the spleen. 
As a corollary to this, surgery of the 
spleen, when there is disease of the reticulo- 
endothelial system, will be successful in 
proportion as it is advised and utilized in 
.cases where the greatest disturbance of the 
reticulo-endothelial system is in the spleen 
itself. Therefore, careful selection of cases 
should be made by proper elimination of 
those diseases from the category of surgery 
where the pathology is equally distributed 
to other organs forming the system. 

Galen, many centuries ago, called the 
spleen the organ “full of mystery.” Today 
this is appreciated probably more than it 
was in Galen’s time. 

tThis is the third of three papers from a sym- 
posium on the Reticulo-Endothelial System, pre- 
sented at a meeting of the Orleans Parish Medical 
Society, March 26, 1928. The discussions of the 
evening follow this paper. 


Dr. W. J. Mayo cites the following story: 

“A senior medical student, up for his 
final examination, was asked by the pro- 
fessor of physiology, ‘What is the function 
of the spleen?’ After considerable hesita- 
tion and digital irritation of the scalp, he 
replied that he had known but had for- 
gotten. ‘What a pity,’ said the professor, 
‘for you are the only man who has ever 
known.’ ” 

The following are some of the functions 
of the spleen as one understands them 
today : 

1. Destruction of effete red cells. 

2. The fragility of the red cells is in- 
creased in certain pathologic conditions 
associated with splenomegaly. 

3. It acts as a scavenger for blood cells, 
and bacteria as a step in the formation of 
pigment. 

4. It prepares bilirubin from the broken 
down hemoglobin. It is found that the 
splenic vein, as a result of red cell destruc- 
tion, contains more bile pigment than the 
splenic artery. 

5. It stores iron. 

6. It destroys platelets. 

7. Thrombo-plastic substances, which 
have to do with coagulation, are formed as 
the result of platelet destruction. 

8. The spleen acts as a filter. 

The purpose of this paper will be to give 
supportive arguments for surgical inter- 
vention in certain diseases of the reticulo- 
endothelial reason. 

In order to do this it will be necessary 
to discuss indications as pointed out by 
physiology and pathology. 

The technic involved in doing a splen- 
ectomy will not be particularly considered 
as the method of procedure has been 
established. 


Reviews 


129 


It may be asked what changes may be 
expected to follow splenectomy. 

Splenectomy for a pathologic condition 
is followed by: 

1. A rise in red cell count. 

2. An increased resistance of the red 
cells to hypotonic salt solution. 

3. A lessened tendency to jaundice. 

4. Spontaneous hemorrhages are rare 
after splenectomy for pathologic conditions. 

5. There is an increase in the platelet 
count. 

6. There is a return to the normal 
bleeding time, probably due to the increase 
in reticulated cells in the circulating blood. 

7. The blood clot becomes retractile. 

8. There is a proliferation of the endo- 
thelial cells in lymph glands and in the 
liver, and a reddening of the bone marrow. 

9. Following splenectomy there is less 
blood in the portal circulation. 

Another question which naturally arises 
is: In which cases are we led to expect 
beneficial results from splenectomy? 

Lest we become too enthusiastic in our 
approach to the problem of surgery where 
splenomegaly exists we must recognize the 
fact that the operation will be beneficial 
directly as the spleen is the seat of the 
greatest disturbance in the disease causing 
the anemia. This is not a new thought, 
simply a reiteration of an old warning. 

I hope to develop this thought. 

ANATOMY. 

The blood supply to the spleen and the 
disposal of its venous blood is of particular 
interest and consideration of it offers room 
for some speculation with reference to the 
association of diseases of the liver and 
spleen. 

The splenic artery is a branch of the 
cealiac axis, the other branches being the 
gastric and hepatic. The splenic vein with 


the mesenteric forms the portal vein. Thus 
we see that the spleen and liver receive 
their blood supply at the same source, a 
wandering cell or organism has an equal 
chance to reach both organs. By means 
of the venous channels the liver receives 
the spleen’s refuse products. 

As a drainage problem one would expect 
to find hepatic disturbances benefitted by 
diminishing the amount of blood which 
passes through it. This is what happens 
following splenectomy in portal cirrhosis. 

Wilkie mentions the fact that a branch 
of the phrenic nerve is supplied to the 
spleen, which accounts for pain in the left 
shoulder in splenic disease. 

In considering diseases of the reticulo- 
endothelial system one must of -necessity 
consider those conditions in which it is 
suddenly called upon for emergency work. 

In some instances something must be 
done to take care of the situation when the 
reticulo-endothelial system is over stimu- 
lated. In other words, give time for the 
system to mobolize reserve forces and to 
bring the same to the front for the defense 
of the patient. 

Such conditions are represented by the 
acute anemias due to hemorrhage and 
septicemia. 

In hemorrhage the sudden loss of blood 
should be replaced while the blood making 
organs have the opportunity of reproduc- 
ing that which has been lost. 

m 

In septicemia, since the reticulo-endo- 
thelial system is the great defensive 
mechanism, and since the great phagocy- 
tising mechanism is taxed to the limit of 
its capacity, over stimulation may result in 
exhaustion and the patient overwhelmed 
by the invading organism. 

Supplying whole blood temporarily adds 
the needed elements and at the same time 
provides a natural stimulation to the 
reticulo-endothelial system. 


130 


Reviews 


Hemorrhage and septicemia. These con- 
ditions cannot be considered without 
mentioning transfusion. Whole blood 
should be the method of election in all 
cases. 

Splenectomy has given spectacular re- 
sults in two of the diseases of the reticulo- 
endothelial system — hemolytic jaundice and 
thrombocji^oylic purpura. 

Splenomegalies in association with 
splenic anemia and the Banti syndrome, 
cirrhosis of the liver, Gaucher's disease, 
and Von Jaksch’s anemia have found a 
place in the category of diseases in which 
benefit may be expected in selected cases 
from splenectomy. 

Pernicious anemia and the leukemias will 
be briefly discussed. 

In presenting this subject from a surgi- 
cal standpoint it is pardonable to give 
briefly the clinical manifestations which 
justify the surgeon in operating. This 
observation is made because it should be 
the conviction of the surgeon that an oper- 
ation of such magnitude should not be 
performed merely at the request of his 
medical confreres. The surgeon should be 
capable of making his own diagnosis. 

HEMOLYTIC JAUNDICE. 

This disease is characterized by spleno- 
megaly, jaundice, the presence of coloring 
matter in the stools, and the absence of 
bile pigment in the urine. 

Examination of the blood reveals diag- 
nostic characteristics. We find increased 
fragility of the red cells, and an anemia 
which at times becomes so great that it 
almost presents a picture of pernicious 
anemia. 

According to Whipple “the excessive red 
cell destruction results in an amount of bile 
pigmentation beyond the ability of the liver 
to excrete and a jaundice results.”^^) 

What is to be expected of surgery in this 
disease? 

We know that splenectomy is followed 
by an increased resistance of the red cells 


to destruction, therefore there will be less 
opportunity for the formation of bile pig- 
ments, hence there should be less jaundice. 

Since these things are facts splenectomy 
should be a specific antidote for a disease 
in which the hypersplenism is associated 
with destruction of the red cells, increased 
pigment formation and increased fragility 
of the red cells. 

The operation of splenectomy for hemo- 
lytic jaundice was first performed by 
Micheli in 1903. The first reported splen- 
ectomy was by Banti, 1912. 

That the results obtained justify the 
means is proven by the statistics of Giffen. 
In November, 1927, he reported 81 cases 
with a hospital mortality of 4.93 per cent. 
Of the 68 living at the present time, 63 are 
in good health. 

All authorities have agreed that the 
diagnosis once made indicates splenectomy 
after proper pre-operative preparation of 
the patient. As proof of this I will cite 
Whipple: “In this disease as in no other 

splenopathy splenectomy gives a brilliant 
immediate as well as permanently a cura- 
tive result.” 

Giffen states that the importance of the 
diagnosis is now so well understood and 
the value of splenectomy so generally 
recognized that it is not necessary to elab- 
orate on them. 

THROMBOCYTO LYTIC PURPURA. 

This disease has attracted a great deal of 
attention during the last few years, par- 
ticularly since the work of Brill and 
Rosenthal in our country in 1923, and the 
work of Katznelson and Franck, as well as 
others in foreign fields. 

The disease is characterized by varying 
degrees of splenic enlargement, hemor- 
rhages from the mucous membranes, and 
under the skin, marked anemia, prolonged 
bleeding time, normal coagulation time, a 
non-retractile clot, and diminution in the 
platelets in circulating blood. 


Reviews 


131 


This disease is one of the apparently 
proven conditions associated with disturb- 
ance of the reticulo-endothelial system. 
The platelets are formed in normal num- 
bers, evidencing the fact that there is no 
disturbance in the megakarocytes of the 
bone marrow from which platelets are 
formed. The hyperactivity of the spleen 
and other members of the reticulo-endothe- 
lial cells destroys the platelets as fast as 
they are formed. Since we know that 
platelets are the only formed elements 
which have to do with coagulation of the 
blood, their destruction, interferes with 
the formation of a retractile clot. The 
efficiency of splenectomy in this disease is 
one of the specific arguments of the value 
of surgery in those cases where the diag- 
nosis is justified. 

Failure to cure a case of purpura by 
splenectomy may be attributable to opera- 
tion done on a case in which either the 
patient has not a true thrombocytolytic 
purpura or as Whipple cautioned “where 
the major part of the thrombocytolysis has 
not taken place in the spleen.” 

Too much stress cannot be laid on the 
importance of an accurate diagnosis. 
Platelet counting requires careful technic. 
A special method of accomplishing this 
was developed by Dr. R. T. Liles while we 
were doing some experimental work on 
this subject several years ago. His methods 
have been published in the Journal of Ex- 
perimental Biology and Medicine. 

All are agreed that the diagnosis indi- 
cates surgical interference after transfu- 
sions have temporarily restored the blood 
balance. 

SPLENIC ANEMIA— BANTI’S DISEASE. 

This disease is characterized by spleno- 
megaly, weakness, progressive secondary 
anemia, low color index and leukopenia. 
In the latter stages the liver is enlarged 
and there is an associated ascites. 

The red cells retain their normal shape, 
“Nucleated forms are rarely seen,” (Pool),, 
and the fragility of the red cells is not 
increased. The coagulation and bleeding 


time are normal, and the platelet count is 
not disturbed. 

Jaundice is rare. At times there are 
hemorrhages. Pool states that you may 
have “purpura epistaxis, hematemesis, 
melena, hematuria, and uterine hemor- 
rhages. The most severe hemorrhages 
come from the uterine and occasionally 
prove fatal.” The etiology of this dis- 
ease is unknown. 

Many theories have been advanced by 
writers and one which I have quoted 
before seems to offer the most rational 
explanation. (Hanrahan.) 

“1. In any consideration of the general 
question of anemia one is confronted with 
the absence of any proved and accepted ex- 
planation of the mechanism of the blood 
balance in the body.” 

“2. We accept that there is a contin- 
uous activity of a widely distributed 
hematopietic tissue which in health is ex- 
actly balanced by a hematocatatonistic 
function.” 

“3. It is obvious that an uncompensated 
disturbance in either of these balanced 
forces will produce the clinical manifes- 
tations recognized as anemia or poly 
cythemia.” 

“4. The conception of a reticulo-endo- 
thelial cell apparatus attempts to provide 
an organ or. system for this function.” 

“5. The presence of splenomegaly points 
to some involvement of the spleen and 
early led to splenectomy on purely empiric 
grounds.” (Hanarahan.) 

Whipple believes that “the good results 
following splenectomy in the early stages 
of the disease favor the view that the pri- 
mary cause is in the spleen and these good 
results are shown not only in an improve- 
ment in the anemia, but an arrest of the 
degenerative changes in the liver, and the 
portal obstruction.” 

Even though the disease is not primarily 
in the spleen the good results may be due, 


132 


Reviews 


as is believed by Dr. W. J. Mayo, by re- 
moving an agent of destruction and by so 
doing the essential causes of the disease is 
rendered ineffective. 

In the past splenectomy has been advo- 
cated particularly in cases before the 
development of ascites. Within recent 
years Sweetser has advocated operation in 
the late stage in order to relieve the portal 
system and thus diminish the work on the 
liver and effectively decrease the ascites. 

Causes of death following splenectomy 
in Banti’s disease: 

Wilkie says that death follows splenec- 
tomy in some cases as a result of mesen- 
teric thrombosis. Cases of Banti’s disease 
may have either a high or low platelet 
count. Those with low platelet count re- 
spond well, those with high platelet count 
“show a tendency to thrombosis following 
splenectomy.” (Howell Evans.) 

Consideration of the results of splenec- 
tomy, in those cases of the Banti syndrome 
associated with ascites, has directed atten- 
tion to the possible value of splenectomy in 
cirrhosis of the liver. It is easy to under- 
stand that in some cases where the spleen 
and liver are enlarged difficulty arises 
when an effort is made to determine which 
enlargement occurred first, the liver or the 
spleen. 

On the above basis splenectomy has been 
done in a few cases of cirrhosis of the liver 
with benefit. 

VON JAKSCH’S ANEMIA. 

“Von Jaksch’s anemia is a condition 
occurring in children and marked by 
anemia, slight enlargement of the liver, and 
marked enlargement of the spleen and 
sometimes an enlargement of the super- 
ficial lymphnodes. The blood picture is 
characterized by a well-marked diminution 
in the number of the red cells and the 
hemoglobin and a persistent leukocytosis of 
varying degree.” 

‘‘Pathology . — There is anemia of the 
organs, often associated with more or less 
fatty degeneration. There may be pete- 


chiae and in some instances there have 
been described hydropic collections in the 
body cavities. The lymph nodes are apt to 
be enlarged and cherry red, the so-called 
hemolymphnodes. The bone marrow is 
dark bluish red and hyperplastic — of the 
rnyeloblastic type. Films made from these 
organs reveal the presence of nucleated 
red cells. The spleen is very large and 
varies in color.” 

“S y mp t 0 m s. — Pallor, weakness, and 
dyspnoea are early symptoms. True jaun- 
dice does not occur. The enlargement of 
the spleen appears early in the disease and 
may reach an extreme degree. The exam- 
ination of the blood must determine the 
diagnosis.” 

“The hemoglobin may be as low as 20 
per cent and the red cells down to 1,000,000. 
The color index is usually less than 1.0.” 

“The erythrocytes show an extreme de- 
parture from the normal. Megaloblasts 
and normoblasts are often seen.’” 

“Leukocytosis is an important element 
in the blood picture. It may be as low as 
10,000 and may reach 50,0010. The differ- 
ential count shows nothing remarkable. 
The fragility of the red cells is normal as 
a rule.” (Pool.) 

Under the head of treatment of this dis- 
ease Pool makes the statement that “In no 
instance is it reported that the patient 
suffered harm as a result of splenectomy, 
so that every patient with von Jaksch’s 
anemia who fails to improve with other 
treatment is entitled to this operation.” 

Considering the pathology as given above 
by Pool the splenic enlargement, hepatic, 
lymph node enlargement, as well as evi- 
dence of hyperactivity of the bone marrow 
seem to suggest that the entire reticulo- 
endothelial system is disturbed and there- 
fore only conservative estimate of the value 
of surgery in this disease should be made. 

GAUCHER’S DISEASE. 

Gaucher’s disease was first described by 
Phillipe Gaucher in 1882. He considered 
it a primary epithelioma of the spleen. 


Reviews 


133 


This disease is characterized by “pro- 
gressive increasing enlargement of the 
spleen, a similar though later enlargement 
of the liver, by a brownish discoloration or 
pigmentation of the skin, chiefly of the 
face, neck and hands, by peculiar changes 
in the occular conjunctiva giving rise to 
cuneiform thickenings extending from the 
corneal margins to the inner and outer 
canthi. It is later accompanied by an 
anemia of the chlorotic type. Hemor- 
rhages occur frequently from the mucous 
surfaces, and occasionally in the skin. The 
blood, even in the early stages, shows a 
persistent leukopenia, which attends the 
disease throughout its entire course; the 
erythrocytes, however, are not altered in 
shape, size or number, nor is there a hemo- 
globinemia, until the disease has lasted a 
few years. Even then the anemia does not 
become very pronounced. The disease is a 
particularly chronic one, often of many 
years’ duration. Jaundice is not present 
and ascites is a very rare accompaniment.” 

“Pathology . — The distinctive feature of 
the disease is the presence in the spleen, 
liver, lymph-nodes and bone marrow of 
peculiar, large cells with a characteristic 
type of cytoplasm.” 

“Bone Marrow . — The consistency of the 
bone-marrow is soft and the color is always 
red, but small white or yellowish areas 
are frequently seen. The large charac- 
teristic cells described in the spleen, liver 
and lymph-nodes are found here in abimd- 
ance.”(®> 

In regard to the treatment there is no 
general agreement. 

Whipple advocates splenectomy with the 
caution that brilliant results must not be 
anticipated because extensive distribution 
of the disease at a distance from the spleen 
may later appear. 

Wilkie cites Guillott’s record of 14 cases 
which had been splenectomized with only 
3 deaths. In the remaining 11 the results 
were extremely satisfactory. 


Brill and Mandelbaum on the other hand 
state that “at the present there is no agent 
which can be depended upon to arrest the 
disease.” “The writer fails to see how such 
a measure (splenectomy) can control the 
course of a disease which is not confined 
to the spleen but which seems to invade 
almost simultaneously all the components of 
the hematopoietic system. To remove the 
disease it would be just as necessary to 
remove the lymph-nodes and the bone 
marrow from the body as the spleen, which 
of course cannot be done.” 

A middle ground may be taken. If the 
spleen seems to be the greatest offender 
and by its enormous size is giving trouble 
it should be removed. It must be remem- 
bered in a disease which is so widespread 
that little should be expected of surgery. 

Diagnosis is of paramount importance. 
Splenomegaly must not be assumed to be 
an indication for splenectomy. In no other 
disease unless it be leukemia is the ques- 
tion of justification for surgery so definite. 

In Gaucher’s disease, like in leukemia, 
the justification for surgery must be proven 
before it is undertaken. 

Time and patient research for the cause 
of Gaucher’s disease will finally dictate the 
proper treatment. 

PERNICIOUS ANEMIA. 

This has been a battleground between 
surgery and medicine for several years. 

Until the work of Minot and his asso- 
ciates was published a few years ago re- 
peated transfusions and splenectomy 
seemed to offer the greatest hope. There 
are still some who believe that the opera- 
tion is being neglected now more than is 
justified. 

Before a conclusion is reached, that it 
should never be done, it certainly will be 
well for all concerned to appreciate the 
fact that splenectomy may still find its 
place in some cases where other methods 
of treatment are used in connection. Such 
a belief was expressed by Giffen, Novem- 


134 


Reviews 


ber, 1927, when he stated: “It is, how- 

ever, not impossible that a splenectomy 
combined with other methods of treatment 
may eventually have a more significant 
place in the management of pernicious 
anemia.”<®> 

The etiology of this disease is unknown. 
It is characterized by marked anemia, high 
color index, progressive weakness, gastro- 
intestinal manifestations, and lesions in the 
spinal cord. 

I believe that certain of these cases after 
repeated transfusions and the Minot diet 
may, with some degree of propriety, be 
operated and beneficial results be obtained. 
Until the etiologic factors are determined 
we will still be in the dark as to the proper 
method of approach. 

LEUKEMIA. 

One might almost dispose of this subject 
from a surgical standpoint by quoting 
Charles L. Green when he says : “It is 

contraindicated absolutely.” 

The attitude that surgery is contraindi- 
cated can be easily appreciated when one 
understands that there is almost a univer- 
sal glandular enlargement. 

In order to cure not only will it be 
necessary to remove the spleen, but the 
entire reticulo-endothelial system. This, of 
course, is impossible. 

In this disease we must look to the 
roentgen-ray, radium, benzol, or possibly 
some therapy which is not yet outlined. 

Before closing I should like to call atten- 
tion again to a phenomenon which occurs 
in some cases following splenectomy; a 
reaction which is similar to that of capil- 
lary poison such as histamin. This reac- 
tion forces one to the conclusion that in 
doing a splenectomy an over-dose of capil- 
lary poisoning may be instantly liberated. 

Comparison with Dale’s work on capil- 
lary poisoning should throw some light on 
this suggestion. 

The practical application, that I believe 
is essential, is that there should be as little 


manipulation of the spleen as possible be- 
cause it may liberate an excess of the 
capillary poison and thus produce a re- 
action. 

CONCLUSION. 

1. Co-operation between internist, phy- 
siologist, and surgeon is of paramount 
importance in diseases of the reticulo-en- 
dothelial system. 

2. Continued research for the etiologic 
factors in order to properly catalogue these 
diseases is important. 

3. Since the reticulo-endothelial system 
is the mechanism for blood balance, we 
must be reasonably sure that the spleen is 
the greatest disturbing factor before un- 
dertaking surgery. 

4. Transfusion in hemorrhage and sep- 
ticemia is rational because of the acute 
disturbance of the reticulo-endothelial sys- 
tem which is present in these conditions. 

5. Splenectomy is followed by brilliant 
results in hemolytic jaundice and thrombo- 
cytolic purpura. 

6. Splenic anemia is greatly benefitted 
by splenectomy. 

7. Gaucher’s disease, von Jaksch’s 
anemia, and pernicious anemia are not 
entirely dependent on surgery for benefi- 
cial results. 

8. Leukemia is not a surgical disease. 

BIBLIOGRAPHY. 

Mayo, W. J. — Editorial. Sur(f., Gyn., and Obs., 33:704, 
1921. 

Whipple. A1 >.t O. — New Orleans Med. and Surg. Journal, 
79:800, 1927. 

Pool, E. and Stillman, R. — Surgery of the Spleen. 

Hanrahan. E. M., Jr. — Arch. Surg., 10 639, 192.5. 

Brill, N. E. and Mandlebaum, F. S. — Tice, Practice of 
Medicne, 8 :305. 

Gffen, H. Z. — Surg., Gyn., and Obs., 45:577, 1927. 

Cohn, Isidore and Lemann, I. I. — Surg. Gyne., and Obs., 
38 :596, 1924. 

Elliott, C. A. and Kanavel, A. B. — Surg., Gyne.. and Obs., 
21 :21, 1915. 

Sweetster, H. B. — Surg., Gyne., and Obs., 33 376, 1921, 

Fisher, D. — Surg., Gyne., and Obs., 35:171, 1922. 

Cushing, E. H., and Stout, A. P. — Arch. Surg., 12 :539, 
1926. 


Reviews. 


135 


Balfour, D. C. — Surg., Gyne., and Obs., 23:1, 1916. 

Moynihan, Sir Berkeley — Brit. Jour. Surg., 8 :307-60, 1920- 
1921. 

Greene, Chas. L. — Tice, Practice of Medicine, 6:740. 

Cohn, Isidore — New Orleans Med. and Surg. Journal, 
78:820, 1926. 

Brill, N. E. and Rosenthal, N. — American Jour. Medical 
Science, 1923. 

Nothnagel’s Encyclopedia — Diseases of Spleen, page 677. 

DISCUSSION. 

Dr. J. H. Musser (New Orleans) : It seems to 

me that this whole subject has been so thoroughly 
discussed and so many facts brought out that it is 
hardly worth while for me to attempt more in the 
way of discussion. Dr. Duval brought up some 
interesting points of a controversial character 
w'hich might be answered in closing by Dr. Lau- 
rens. 

One disease I might mention, not mentioned 
tonight, which it seems is outstanding evidence of 
disease of the reticulo-endothelial system, and 
that is infectious mononeucliosis, which is primar- 
ily a disease of this interesting system. 

In conjunction with remarks that were made 
from the surgical standpoint, I would emphasize 
one particular idea, that is: despite the enthusi- 
asm in the study of a definite condition and our 
enthusiasm for the remedial measures which some- 
times help in certain types of cases, follow Dr. 
Cohn’s suggestion that we do not become over- 
enthusiastic. Because the spleen is responsible 
at times for diseases of certain types does not 
follow that all types of blood disease would re- 
quire splenectomy. 

Dr. Pigford took up very thoroughly indeed the 
various diseases which play a part in the disturb- 
ance of the physiology of this reticulo-endothelial 
system. 

Splenectomy is followed invariably by an en- 
largement of the so-called hemolymph nodes and 
in experiments with animals they develop with re- 
markable rapidity, explaining in part why so often 
after the spleen is removed the anticipated result 
is rather short-lived. I have had the opportunity 
of following up four or five individuals who were 
splenectomized a few years ago, and I always 
hoped that I would have the opportunity of exam- 
ining these individuals post-mortem. Thus far 
none of them have died and it may be that I will 
never have this chance. But I would like to call 
the attention of those surgeons who have per- 
formed this operation some years back to keep in 
touch with their patients and in the event of death 
to get an autopsy, if possible, and study carefully 
the results. 

Dr. E. D. Fenner (New Orleans) : We hear be- 
fore this Society practical papers that tell us the 


experience of the writers, and we have, some- 
times, papers of the type we have listened to to- 
night, for which I think we should be grateful. 
Looking around this audience, I take it that many 
are like myself, and feel that much that we have 
heard is still a little above our heads, and that 
we are looking up and out at an aeronautic ex- 
pansion of the present horizon of medicine. But 
these papers, while most of us do not yet know 
a great deal about the problems they present, 
have given us something to think about. And 
thinking is always good for us. 

I have but one word more to add. The highly 
technical character of these discussions recalls to 
my mind a negro maid, who worked for years in 
my mother’s household, whom I heard speaking to 
the cook about my brother. She said: “I cer- 

tainly do like to listen to Mars Charlie converse; 
he does talk such high dictionary.” 

Dr. Russell Pigford (closing) : I should like to 
call attention to the apparent geographical dis- 
tribution of polycythemia vera. It is very rarely 
seen in tropical and sub-tropical regions, while 
the greatest incidence seems to be in the cooler 
climates. The greatest number of case reports 
have been from the northern and eastern parts 
of this country and the northern countries of 
Europe. That it does occur in sub-tropical cli- 
mates, however, is evidenced by the report of a 
case occurring recently in the service of Dr. Mus- 
ser at Charity Hospital. 

Dr. Henry Laurens (closing) : In the analysis 

of this interesting system one of the chief diffi- 
culties we encounter is correlating what happens 
in health and what happens in disease. In this 
connection I am reminded of a remark that “It is 
in her moments of abnormality that Nature re- 
veals the secrets of her laws.” I think, however, 
that Professor Duval is a little too broad in his 
concept of the reticulo-endothelial system. In the 
embryo the general endothelial bed is highly pha- 
gocytic. It has been shown, however, in a recent 
paper (Beard, J. W., and L. A. Beard. Amer. 
Jour. Anat., 40:295-314, 1927) that as the embryo 
develops the phagocytic capacity of certain por- 
tions of the endothelium increases, while at the 
same time that of other vascular endothelium 
diminishes. The portions which show the increase 
(the “specific endothelia”) are those I have out- 
lined as being included in the reticulo-endothelial 
system. Aschoff concedes that the perivascular 
cells of the kidneys and adrenals and reticular 
cells of the pancreas belong to this system in 
the broader sense of the term. If included at all, 
the interstitial cells of the testis and the reticu- 
lum cells of the thymus would represent only 
an accessory branch of the reticulo-endothelial 
system. According to Aschoff, only the special- 


136 


Case Reports and Clinical Suggestions. 


ized endothelium of the liver, spleen, bone mar- 
row, lymph nodes, adrenal and hypophyseal capil- 
laries belong to the reticulo-endothelial system, 
the vascular endothelium elsewhere being unable 
to produce mobile phagocytes. 

In answer to Dr. Fossier’s request for infor- 
mation about this recent work dealing with the 
lungs as a blood-forming gland, I am afraid that 


I can not be of service. The function of the 
alveolar phagocytes is an interesting question. 
The alveoli, however, are lined with epithelium, 
and not endothelium, and that, I think, throws 
this particular portion of the organism out of 
our present consideration. It has been shown a 
number of times that these cells are highly phag- 
ocytic and ameboid and behave like histiocytes. 


CASE REPORTS AND CLINICAL SUGGESTIONS 


GANGRENOUS APPENDICITIS 
OCCURRING SIMULTANE- 
OUSLY WITH SCARLET 
FEVER. 

J. M. BODENHEIMER, M. D., 

AND 

T. J. FLEMING, M. D., 

Shreveport, La. 

To quote Woody d) “The combination or con- 
comitant infections are not limited to two, triple 
infections are not uncommon and quadruple are 
not unknown. In fact their number may be as 
many as the infections to which a given indi- 
vidual has been exposed, though they do not 
necessarily all appear during the acute stage of 
one or the other disease.” 

“We have seen scarlet fever combined with 
varicella and whooping cough, with diphtheria, 
measles and epidemic cerebro-spinal meningitis, 
also scarlet fever, diphtheria, varicella and whoop- 
ing cough, with recovery.” 

Scarlet fever as a surgical wound infection is 
not unknown, but nowhere have we been able to 
find reported a case of gangrenous appendicitis 
concurrent with scarlet fever. 

A High School boy, sixteen years of age, was 
brought to our office to be treated for a severe 
case of acne of face and back. Upon examination, 
a scarlet fever rash was observed upon chest, ab- 
domen and inner surface of thighs. Temperature 
102° F., pulse 100. Throat and tongue were 
characteristic. The diagnosis of scarlet fever was 
confirmed by Dr. M. S. Picard. 

The following morning the patient’s general 
condition was splendid with eruption and straw- 
berry tongue more marked. Temperature 99.5°, 
pulse 90. About noon he was suddenly seized 
with pain in epigastrium following the inges- 
tion of a banana. His mother administered the 
usual household remedies including Epsom salts, 
which he fortunately vomited, and securing no re- 
lief, one of us was called. 

(1) — ^Tice, Practice of Medicine. 


After the customary lecture on the promiscuous 
use of purgatives in “stomach ache,” tincture of 
opium, five minims every two hours for the relief 
of pain was prescribed. The following morning the 
mother reported that the boy had continued to 
vomit and that the pain was even more severe than 
before. He was now suffering with cramping over 
the entire abdomen and with watery stool every 
five minutes. There was no definitely localized 
point of tenderness, and no muscular rigidity, al- 
though he did complain of some soreness upon pal- 
pation. At 6 p. m., 30 houis after the initial at- 
tack of pain in the epigastrium, there was a well 
localized point of tenderness in the neighborhood 
of McBurney’s point. Temperature 102°, pulse 
110. At 9 p. m. temperature 103.5°, pulse 120. 
Blood report by Dr. C. E. Hammer, was as follows; 
Total white count, 8,500, with 78 per cent of 
polymonphonuclears. 

In spite of the fact that he had been suddenly 
relieved of pain, or rather because of that symp- 
tom, togther with climbing temperature and pulse, 
we made a gridiron incision directly over the 
point of greatest tenderness and delivered a large 
gangrenous appendix enfolded in the omentum, 
which ruptured, exuding very foul smelling pus. 

We simply tied off the appendix, cauterizing the 
stump and draining with a cigarette drain. 

The patient made an uneventful recovery, the 
healing being in no way impaired by the scarlet 
fever. There were several problems that pre- 
sented themselves to us in this case. The first 
was: what would be the results of an operation 
on a case of scarlet fever? Second: how would 
the disease effect the healing? Our results in this 
case were not influenced in the slightest by the 
scarlet fever. 

We were confronted with practically a normal 
blood count where either condition should give a 
leukocytosis with marked increase in polymon- 
phonuclears. In this case the gangrenous condi- 
tion governed the blood picture. 

There is one lesson from this report which un- 
fortunately some of our doctors have never 
learned. Clinical judgment still holds supreme 
rank in deciding a course of action. 


Case Reports and Clinical Suggestions. 


137 


A CASE OF ADVANCED BANTI’S 
DISEASE FOLLOWED BY 
SPLENECTOMY. 

H. E. GUERRIERO, M. D., 

Monroe, La. 

The syndrome of enlarged spleen and 
aevere anemia was first fully described by 
Guido Banti in 1894. He was the first not 
only to call attention to the cirrhosis of the 
liver that is so characteristic of the late 
stages, but also to offer evidence as to the 
primary relation of the spleen, and to sug- 
gest its removal as to the most logical 
treatment. 

Mr. S., a white male, age 49 years, by occupa- 
tion a carpenter, was first seen December 5, 1927, 
complaining of vomiting of blood, general weak- 
ness and soreness over splenic region. 

Present illness: Patient was in good health 

until present illness, first noticed by him in 
November, 1926, at which time he felt perfectly 
well except for an occasional attack of head cold 
associated with soreness over spleen and general 
neuralgic pain through his gums and teeth, other- 
wise he felt in perfect health. The soreness over his 
spleen was always preceded by an acute head cold. 
He had several such attacks up until July, 1927, 
when he vomited a very large amount of fairly 
bright red blood for the first time. During the 
month of July he had five such hemorrhages in 
all. Two transfusions (500 cc. citrated blood) 
were given during the month. Patient said he 
improved follovcing the transfusions, bxit never re- 
gained his full strength. During and following 
the hemorrhages patient suffered no gastric or 
other discomforts except for a general weak feel- 
ing and soreness over splenic region, no melena 
present except on days following hemorrhages, no 
diarrhea. Patient suffered no further discomforts 
other than what has previously been mentioned 
up until December 1, 1927, when he again vomited 
blood in large amounts without any associated 
pain or discomfort. Had three such hemorrhages 
and was sent to the hospital on December 5, 1927. 

Appetite has always been good, there has been 
no gastric disturbance, no diarrhea, and no melena 
except after hematemesis. Symptoms of respira- 
tory, cardio-vascular and urinary system dysfunc- 
tion have been entirely absent. 

There has been no loss of weight before he 
first vomited blood in July, 1927. Since this time 
he has lost about twenty-five pounds. 

Physical examination : Reveals a white male 

well developed and fairly well nourished, lying 


flat of back, apparently very comfortable. Patient 
looks very anemic, skin having a lemon tinge 
color. Approximate height 6 feet. Approximate 
weight 145 pounds. Skin is negative except for 
lemon tinge suggesting marked anemia. There is 
no glandular adenopathy. Pupils react normally 
to light and accommodation. Patellar reflexes are 
active and equal. 

Head : No tenderness over sinuses on marked 

pressure, (a) Eyes, no scleral jaundice, conjunc- 
tivae pale, (b) Mouth, majority of teeth removed 
August, 1927. Remaining teeth poorly kept, but 
are in fairly good condition. No evidence of pyor- 
rhea alveolaris. No pus could be expressed from 
tonsils. 

Chest: Symmetrical. Ribs prominent. Lungs: 
Negative. Heart: No cardiac enlargement; sys- 

tolic murmur present at apex, not transmitted, 
functional in type, possibly due to marked anemia. 

Abdomen appears somewhat distended, with 
bulging in flanks suggesting fluid. Veins over the 
lower abdomen plainly visible and appear con- 
gested. Palpation reveals no tenderness or rig- 
idity. Liver is not palpable. In splenic region a 
very hard smooth tumor mass is present. Tumor 
extends to level of umbilicus downward and to mid- 
line to the right. Mass is somewhat movable and is 
somewhat tender on marked pressure. On percus- 
sion shifting dullness was present. Extremeties: 
No edema present. No arteriosclerosis present in 
radial vessels. Blood pressure was 98 systolic, 64 
diastolic. 

Latter history: Patient was first seen on De- 

cember 5, 1927. Blood picture at this time showed : 
Erythrocytes 1,810,000, hemoglobin 35 percent 
(Talquist), color index .9, leukocytes 20,550, 
small mononuclears 19 per cent, large mononu- 
clears 1 per cent, neutrophils 80 per cent. No 
malaria plasmodia found and no nucleated red 
cells. Polychromatophilia and anisocytosis present. 

December 6: Wassermann, negative; kidney 

function test, 50 per cent; coagulation time, 4 
minutes; bleeding time, 1 minute; fragility test 
for erythrocytes, normal. 

Urinalysis : Negative except for trace of indi- 

can and a few pus cells. 

December 7 : Almost daily blood counts 

showed but slight variation in the blood picture 
despite another transfusion of 500 cc. of citrated 
blood. 

December 30: ‘Splenectomy done. About 4000 

cc. of straw colored fluid found in the abdomen. 
Spleen was found to be very hard and about seven 
times its normal size, was adhered to the dia- 
phragm above and to the abdominal wall laterally. 
Stomach negative. Liver showed a fairly well 


138 


Case Reports and Clinical Suggestions. 


advanced cirrhosis. Immediately following opera- 
tion 500 cc. citrated blood given as transfusion. 
Patient reacted from operation in very poor con- 
dition. Five hundred cc. 10 per cent glucose solu- 
tion given as infusion twice daily for four days. 

January 2, 1928: Patient improving. Erythro- 

c>i;6s 2,050,00, hemoglobin 40 per cent. 

January 4: General condition good. Erythro- 

cytes 2,720,000, hemoglobin 40 per cent. 

January 9: Blood picture: Erythrocytes 2,400,- 

000, hemoglobin 40 per cent. Patient complaining 
of soreness in right arm, which was found to be 
slightly swollen, red and very painful to touch. 
Slight edema of forearm and hand present. Ten- 
derness present over basilic vein with evidences of 
thrombophlebitis present. Temperature 102°. 
Diagnosis of thrombophlebitis of axillary vein 
was made, following transfusions and infusions. 
Extremity was splinted and elevated. 

January 11: Edema of forearm and hand dis- 

appearing, temperature curve dropping. Operative 
wound healed. 


January 16: Blood picture: Erythrocytes 

2.560.000, hemoglobin 40 per cent. Patient put 
on Minot-Murphy liver diet. 

January 17: Discharged from hospital. 

Pathological findings: Examination of spleen 

removed at operation. Weight 1500 gms. Cap- 
sule enormously thickened consisting of dense 
connective tissue. Microscopic examination re- 
veals a marked increase of connective tissue 
throughout organ. Malphigian corpuscles are ab- 
sent from section examined. 

Diagnosis : Splenomegaly; fibrous. The histo- 

logical picture is that of late Banti’s disease. 

Progress notes: Patient up and about, grad- 

ually regained full strength. March 25, 1928, no 
return of ascites. Blood picture: Erythrocytes 

3.750.000, hemoglobin (Dare) 58 per cent, total 
leukocytes 19,000, neutrophils 52 per cent, small 
mononuclears 46 per cent, large mononuclears 2 
per cent. No nucleated reds were observed. 


HEALTH THROUGH ADVERTISING. — The 

health motif has taken the advertising world by 
storm. Whether it be safety razors, a new break- 
fast food or rubber heels; tooth brushes or denti- 
frices or a gargle for the garrulous throats of the 
multitudes, the banners of improved health are 
flaunted in the van, and the rustling of their silky 
folds obscures the music of the steady stream of 
cold cash that pours into the coffers of the adver- 
tisers. The California fruit growers of Los An- 
geles continue to rid the world of acidosis, aided 
by a stupendous advertising campaign in the lay, 
and, we fear, in the medical press. Fleischman’s 
yeast (none other will do) continues to remove 
acne as if with sandpaper, and restores to health 
the racked and costive bodies of famous athletes, 
actresses and opera singers. The list of renowned 
health propagandists is a long one; the Cuban 
sugar planters are about to convince a willing pop- 
ulace that sugar plays no part in obesity, and cer- 
tainly none in diabetes. Twenty-two thousand 
one hundred and fifty-two witnesses say, in the 
case of The People vs. Caffein, “My nervousness 
vanished when I changed to Postum!” ’Tis for 
your own good health — and the health of your 
family — you must buy a certain well known elec- 
tric refrigerator. Only with one particular tooth 
brush can you gain gloriously white teeth and coral 
firm gums. To make this more effective, how- 
ever, the danger line must be scrubbed with a 
special tooth paste, and the acme of health is 
achieved when you put new youth into your stride 
vath the buoyant, lasting spring of rubber heels. 


Indeed it reads like poetry. Enjoy shoe health, 
a St. Louis firm tells us, for whatever your avo- 
cation, good health is a vital asset, and the shoes 
you wear are a very important factor in keeping 
you physically fit. Cod liver oil raises the 80 per 
centers to 100 per cent, health. The average 
man of 35, we are told by the American Barley 
Corporation, is beginning to slip physically — to 
lose that vital, physical force, that buoyant enthus- 
iasm, which makes his ideas “go across”. Cream 
of barley is a demulcent; it sends men to work 
to win. 

At the other end of the health rainbow — and 
remember that rainbows are elusive — lies what we 
who are engaged in the profession that deals with 
health and disease believe to be the true pot of 
gold; the health examinations; advice, as sound 
as we can make it, on hygiene and right living; 
early and correct diagnosis if possible; ethical 
treatment, and the intelligent education of the 
public along the lines of health and disease. We 
may not be accomplishing, always, the end 
towards which we are striving, for we are often 
the \dctims of personal bias or of lack of knowl- 
edge, and in our own ranks are those who do not 
fight the good fight. In the main, however, we are 
trying and we are accomplishing. Many diseases 
have been conquered and the span of life has 
been lengthened, and this without the aid of very 
many of those vendors of profitable products whose 
watch word is halitosis, for Lister, though less 
well known, has served humanity better than has 
Listerine. — Boston M. & S. J., 198:870, 1928. 


Editorials. 


isy 


NEW ORLEANS 

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The State Cctmmittee on Public Policy 
and Legislation, under the able guidance 
of Dr. B. A. Ledbetter, deserves the hearty 
congratulations of every medical man in 
the State of Louisiana, be he a member of 
the Society or not. At the expense of an 
immense amount of time and labor, this 
most efficient committee has been respon- 
sible largely for the checking off of many 
pernicious bills which have been presented 
at the last session of the State Legislature. 
These men have worked diligently and 
faithfully, have neglected their other ac- 
tivities in order to give time and energy 
to their duty to their fellow practitioners. 


They have attended ^he sessions of the 
Legislature, have appeared before com- 
mittees, and have spent days at Baton 
Rouge when necessarily their income from 
medicine must cease while they are away 
from their homes. They have been re- 
sponsible for the squashing of such bills 
as the Chiropractic Bill before it got out 
of Committee, appearing there at the ses- 
sions of the Committee explaining fully 
and cogently just why such bills were 
harmful. To Dr. Ledbetter and his able 
co-workers. Dr. Leon J. Menville, Dr. Roy 
B. Harrison, Dr. P. T. Talbot, Dr. E. L. 
Leckert, the Committee from the Orleans 
Parish Medical Society, headed by Dr. Jules 
Dupuy ; the Louisiana State Board of Medi- 
cal Examiners, and others who have as- 
sisted, the thanks of the medical profession 
are due. 

It seems like a very small thing indeed 
to ask the members of the Louisiana State 
Medical Society to contribute $1.00 in part 
towards the expenses of these men while 
in Baton Rouge. It might be borne in 
mind that only a relatively small percent- 
age of this amount is actually used to de- 
fray the expenses incurred directly by the 
members of the Committee. The greater 
part of it goes to pay for legal advice and 
counsel, secretarial help, telegrams, post- 
age, stationery and so on. Surely, no dol- 
lar that the medical man i,in this State 
spends in the coming year will yield him 
a greater dividend than this one small dol- 
lar which he is asked to give to meet these 
expenses. Actually the momentary cost of 
what the members of the Society might 
have to pay for the value received, would 
be ten or twenty fold greater were it not 
that their services were given voluntarily 
and gratis by all those who helped at Baton 
Rouge. 

Senate Bill Number 241 is probably the 
most important one that was introduced 
in the State Legislature from the point of 
view of the physician. The repeal of the 
narcotic act was also important, as it will 
obviate considerable time and trouble to 


140 


Editorials. 


doctors of medicine. In addition to these 
bills, Senate Bills Numbers 115, 265, 100, 
157, 234, and House Bills numbers 149, 501, 
504, 302, 171, 388, 390, 705, 93, 414, 530, 
354, 709, 315, all had contained certain 
features in which the medical profession 
were interested. It may be seen from a 
superficial view of the number of bills that 
were introduced relating to medicine and 
medical activities that the Committee had 
a very large job to carry through to a suc- 
cessful conclusion. 


STATUS LYMPHATICUS. 

Considerable healthy skepticism has 
arisen in the past few years in regard to 
the indefinite and about which little is 
known condition spoken of as status lym- 
phaticus. More particular has been the 
growing conception that an enlarged thy- 
mus in a child dying of inexplicable cause is 
not responsible for the death of that child. 
Pathologists are appreciating the fact that 
enlargement of this gland, and the enlarge- 
ment of the lymphoid tissue throughout 
the body, is a normal finding. Otolaryn- 
gologists have long appreciated that big 
tonsils are part and parcel of a child’s 
makeup. Unfortunately the opportunity 
of examining the body of a child dead as a 
result of some traumatic cause rarely takes 
place. In the past the pathologists’ ideas 
of a normal child have been gained from 
examination of children who have died 
from long continued wasting disease in 
which one of the salient features is the 
rapid atrophy of the lamphoid tissue. 
Marine*, in a recent paper, discusses the 
condition of status lymphaticus most fully. 
He concedes that there are probably a very 
small group of patients who have an ana- 
tomical abnormality evidenced by marked 
increase in the lymphoid tissue, small 
suprarenals, lymphocytosis, and hypoplas- 
tic aorta; the most important feature of 
this condition being the insufficiency of the 
adrenals, because Marine has found that 
removal of the adrenals is followed by a 

^Marine, David: Arch. Path, and Int. Med., 5:661, 1928. 


much lowered resistance to toxins and 
poisons. He advances the idea that involu- 
tion of the human adrenal cortex occurring 
after the child had been born may explain 
the condition which we speak of as status 
lymphaticus in young children. Under any 
circumstance this condition is very uncom- 
mon ; the explanation for it is not entirely 
convincing; enlargement of the thymus is 
not a diagnostic sign of infallability ; and 
certainly there is still much to learn about 
these inexplicable deaths which we have 
been wont to call status lymphaticus. 


HISTORY OF THE LOUISIANA 
STATE MEDICAL SOCIETY. 

The History of the Louisiana State 
Medical Society, made possible by a special 
act of the House of Delegates, is progress- 
ing rapidly and favorably under the able 
editorial guidance of Dr. Rudolph Matas. 
For the past three months Dr. Matas has 
had working under his direction a Secre- 
tary-Librarian who has already compiled a 
great many interesting and important 
data. The work will progress more rapidly 
and could be accomplished in much quicker 
time if the co-operation of the parish and 
di.strict society secretaries was more whole- 
hearted than it is. Considerable difficulty 
has been experienced in securing informa- 
tion from these sources. It is hoped that 
the Secretaries will appreciate that much 
of the worth of the volume will necessarily 
have to depend upon the aid that they can 
and will give. 

A discouraging feature, which it is be- 
lieved is due entirely to tardin.ess rather 
than to unwillingness, is the small num- 
ber of prospective subscriptions. Less 
than one-third of the subscriptions which 
will make the work a financial success have 
been received. It is most earnestly hoped 
that the men who intend to subscribe to 
this interesting history of the activities of 
the Society will send in their subscriptions 
at the earliest possible moment. It will 
hearten and encourage the Committee 
materially to know that their work is ap- 
preciated. 


HOSPITAL STAFF TRANSACTIONS 


SOUTHERN BAPTIST HOSPITAL. 

I June 12, 1928. 

The regular monthly meeting was held June 12, 
[ 1928. 

CASE OF MENINGITIS. 

Dr. Charles S. Holbrook presented a very inter- 
esting case of meningitis The patient was a little 
girl of eleven years. She was admitted to the 
hospital on the twenty-fifth of last month to the 
service of Dr. Carroll W. Allen. As soon as Dr. 
Allen saw the child he realized it was not a sur- 
gical condition, and called Dr. Holbrook in con- 
sultation. Her history, as it is recorded on her 
chart, is as follows : She came into the hospital 
complaining of chills and fever. The present ill- 
ness began yesterday morning; that is, the day 
I previous to admission, when patient had chills 
[followed by high fever, and, at this time, there 
[was some nausea and vomiting. Calomel was 
given, which was retained. She complained after 
[this of pains in her back and generalized pains, 
i especially in various joints. She has been in a 
mild stupor since yesterday morning. She has 
had very severe headaches several hours before 
;her admission to the hospital. 

When Dr. Holbrook saw the patient in the hos- 
pital, she was extremely restless, throwing herself 
backward and forward across the bed and was 
unable to co-operate. It was impossible to get an 
answer from her or to get her to talk. She com- 
plained of pains in the head and of almost any- 
thing. Even a touch on the abdomen hurt her. 
rhe marked symptoms were restlessness and 
;loudy memory. She had rather high fever, 103°. 

^ blood picture showed the leukocypte count to 
)e 37,000, of which 90 per cent were neutrophils. 

)n examination it was found that her neck was 
tiff. A spinal puncture was taken immediately 
inder gas anaesthesia. The fluid was decidedly 
loudy. Examination showed it to have about one 
housand cells, almost entirely neutrophils. Then, 
bout one hour from this, another anesthetic was 
iven the patient and 15c. c. of serum was injected, 
he next day another 15c.c. of serum was given, 
t which time it was again necessary to give an 
aesthetic. After this, however, it was not neces- 
iry to give a general anesthetic on subsequent 
:casions. After the fourth intraspinal treatment 
le spinal fluid was negative. After the first treat- 
ent of serum she was very much better. Her 
mperature was less, and she became conscious 
id co-operative. The fluid was so clear after the 
'Urth dose that the fifth dose was hardly neces- 
ry. She has gradually gotten better. Now, the 
itient is quite well and is going home tomorrow. 


Dr. Holbrook feels that the splendid result is 
largely due to the early recognition of an unusual 
disease in the small town in which the child lived. 
Had the child waited one, two or three days 
longer, irreparable damage would have been done, 
and if she would have come through with her life, 
there would have been an aftermath of deafness,' 
lameness, blindness, or imbecility. 

Dr. Walter J. Otis, in discussing Dr. Holbrook’s 
case of meningitis, said he thought Dr. Holbrook 
has covered the situation very thoroughly, and has 
treated this disease correctly. The aftermath is 
what must be guarded against, the effects after 
the disease is supposed to have cleared and the 
patient has apparently recovered. The child ap- 
peared to him to be a case more of a choreic type. 
He noticed two or three tick-like movements as 
she sat in the chair. It is probably a reticulis, 
which is very painful. 

Dr. Carroll W. Allen said he saw the child one 
afternoon and immediately recognized its nature. 
He called for Dr. Holbrook to see the patient im- 
mediately, and Dr. Holbrook responded in a short 
while. 

Dr. Charles S. Holbrook stated another inter- 
esting point in this case, which he did not men- 
tion. The lady who came in the room with the 
child tonight has a son who attended college. 
While in college the boy developed menigitis and 
it was several days before a diagnosis was made 
and treatment given. The boy recovered, but his 
mental condition has never been well and he is 
totally deaf. He was back home in the same town 
as this child for sometime, about eight or ten 
weeks, before this child had become ill. There 
may have been some connection between this boy 
as a carrier and the development of meningitis 
in the child. The authorities of the town made 
cultures of the family and those who came in con- 
tact with the boy, but no organisms or carriers 
were found. 

SECOND CASE OF MENINGITIS. 

Dr. Charles S. Holbrook presented a second 
case of meningitis. Mr. J. P., medical student, 
aged 24 years, admitted to hospital May 9, 1928. 

On May 8, in the afternoon, patient complained 
of chilly sensation and of feeling feverish. Tem- 
perature was taken that afternoon and was 102°. 
There was moderate headache, general malaise, 
and pains over the body. The symptoms were 
similar to those of a beginning influenza, or other 
infectious disease. The above symptoms increased 
over night, until he was admitted the following 
morning to the hospital. 


142 


Hospital Staff Transactions 


Examination showed a well developed and well 
nourished acutely ill young man. The general 
examination was negative, except for slight 
rigidity of the neck and a moderately well devel- 
oped Kernig’s sign on both sides. 

A spinal puncture was done and the fluid was 
found to be under considerable pressure. There 
was a distinct cloud. The cell count was 1,000; 
globulin — four plus; Wassermann — negative; in- 
tracellular gram negative diplococci were found 
in moderate numbers. The blood picture on May 
9 was 20,900,-96 per cent neutrophils. May 
10, the day of the spinal puncture, there were 
16,000 leukocytes with 93 per cent neutrophils. 

After finding the above mentioned organisms 
in the spinal fluid, another spinal puncture was 
immediately done and 30c. c. of polyvalent anti- 
menengococcic serum was given intraspinally and 
30c.c. intravenously. May 11, 25c. c. of spinal 
fluid was removed. It was clouded, but seemed 
less so than on the previous day. Thirty c.c. of 
serum was given intraspinally and 30c.c. intra- 
venously. His mental condition, which had been 
decidedly clouded the first few days, showed a 
marked improvement. He was perfectly clear in 
every respect. On the twelth of May and also 
the thirteenth, 30c.c. of serum were given intro- 
spinally each day. At this time the fluid was 
decidedly less clouded and had taken on a greenish 
tinge. No serum was given on the fourteenth. 
On the fifteenth, the spinal fluid appeared very 
clear. Thirty c.c. of serum was given intraspin- 
ally. It is felt that this latter dose could have 
been omitted. 

Spinal punctures were done every day for two 
or three occasions. The fluid remained clear. May 
25 the patient was discharged. 

Cultures w'ere attempted from the blood with 
negative results and the organism could not be 
grown from the spinal fluid. 

Upon admission, temperature was 104°; pulse 
120. On the tenth, temperature was 104.6°; pulse 
130. At this time the serum was given. The 
temperature fell to 100.2°, and did not rise again 
above this, except the time when he had a serum 
reaction. Cultures from the nose and throat did 
not show any organisms similar to those found in 
the spinal fluid. 

The patient made a complete recovery and was 
able, within three weeks, to leave the hospital to 
finish his final examinations in medicine. He had 
an internship, but has been advised to take a 
vacation of ten or twelve weeks before entering 
into this work. 


A REVIEW OF THE USE OF THE SEDIMENTATION 
RATE AS EMPLOYED IN THE SOUTHERN 
BAPTIST HOSPITAL. 

Dr. Edwin H. Lawson said the procedure known 
as the estimation of the sedimentation rate of 
erythrocytes is by no means an innovation, for 
Galen noticed that the settling of erythrocytes 
was more rapid in cases of infection than in the 
blood of normal individuals. This observation has 
since been noted by other men, such as John Hun- 
ter, Virchow, Fahraeus, Hober, and, recently, Lin- 
zenmeier. Cutler, and Westergreen have each 
devised a technic for the estimation of the sedi- 
mentation rate. The technics vary only in the 
type of tube used and the percentage of anti- 
coagulant, namely, sodium citrate, used. All ol 
the technics consist of mixing the various amounts 
of blood, with an anti-coagulant, and of placing 
this solution of blood and citrate in a tube and 
noting the time required for the erythrocytes t( 
settle. Two types of tube most generally used art 
the Linzenmeier and Cutler types. The formei 
requires a small amount of blood, but the latter 
a graphic method, is more useful in the follow-uj 
work, as the increase or decrease in sedimentatioi 
rate, using this method, can be seen at a glance. 

The estimation of the sedimentation rate ha;, 
been used in quite an assortment of cases, beinj 
most frequently used in the prognosis of sue), 
diseases as tuberculosis, and other pulmonary con 
ditions, appendicitis, and most particularly acut 
pelvic infections. Polak has advised the use o 
the sedimentation rate as an indication of the tim 
to operate on pelvic infections, and has found tha. 
following a pelvic operation a low sedimentatio 
rate is an early index of a beginning peritoniti 
or perimetritis. In tuberculosis, the sedimentj 
tion rate is directly proportionate to the activit 
of the disease; and in acute polyarthritis the sed 
mentation rate is directly proportionate to th 
clinical symptoms. 

The following is a list of cases in this hospita 
with an estimation of the sedimentation rate, usir 
the Linzenmier technique: 

Mrs. T. Diagnosis: Acute pelvic inflammatoi 
disease. Four determinations made ; two of whi( 
ran eighteen minutes, and two of which ran tweni| 
minutes. 

Mrs. R. Diagnosis: Fibroid. Forty minutes. 

Mrs. P. Diagnosis: Chronic endometriti 

Seventy minutes. 

Mr. S. Diagnosis: Acute infectious arthrit. 
Three determinations made: two of which r: 
fourteen minutes, and one of which ran thirt 
two minutes. 

Mrs. M. Diagnosis: Chronic myocarditis. F i 
teen minutes. 


Hospital Staff Transactions 


a43 


Mrs. L. Diag^nosis: Influenza. Twenty minutes. 

Miss R. H. Diagnosis: Acute lymphadenitis, 
ixty minutes. 

Miss H. Diagnosis: Supprative pleurisy. Ten 
linutes. 

Mr. D. Diagnosis: Acute appendicitis. Twelve 
inutes. 

An analysis of these cases each show that in 
jneral the rapidity of the sedimentation rate is 
irectly proportinate to the acuteness of the ill- 
?ss. In most of these cases the sedimentation 
ite is of diagnostic and prognostic value when con- 
dered in conjunction with other laboratory find- 
gs and the clinical symptoms, that there is some 
dation existing between the severity of the dis- 
ise and the increase in the sedimentation rate, 
id that it may be of some aid to the surgeon in 
iciding when to operate in infectious cases. 

Dr. Lawson also presented three charts, repre- 
nting graphically the sedimentation rate in vari- 
is diseases, the relation of the sedimentation rate 
the white cell count and a drawing of the two 
pes of tube most generally used. 

DISCUSSION. 

Dr. Carroll W. Allen, in discussing this subject, 
ited that the sedimentation rate is a clinical aid 
studying the prognosis of a case and in deter- 
ining the time to operate. He suggested that if 
is test was intelligently used it would offer an 
:tensive range of usefulness. 

Dr. Thomas B. Sellers said he has run a sedi- 
snation rate test on all of his pelvic infectious 
ses for several months and on two ectopic cases, 
e also said that in an interview with an out-of- 
wn doctor, he learned that the sedimentation 
te was run routinely in his hospital on all pelvic 
factious cases. It is found to be more depend- 
le than the blood count as a prognostic and a 
agnostic agent, though it does not necessarily 
minate the blood count at all. The sedimenta- 
>n test has been used also routinely to determine 
e time to operate. Many times in these pelvic 
ses with a perfectly normal temperature and 
perfectly normal blood count there is found, 
ion opening the abdomen, exudate and friable 
hesions. It is often realized, after opening the 
domen, it would have been much better to have 
owed these cases to rest two, three, or four 
leks longer. The sedimentation test' usually 
tes this particular type of case and determines 
J time to operate. The rule is that in sedimen- 
;ion rates of less than one hour, no surgery 
luld be done. 

There is another interesting point in the sedi- 
intation rate. It is supposed to be normal in 
;opic cases and rapid in infectious cases. If 


this is true, and in two cases that Dr. Sellers has 
tried this fact has been borne out, it is of great 
diagnostic value in differentiating between ecto- 
pic and subacute pelvic diseases. One big advan- 
tage in the sedimentation rate is that it can be 
used in the rural districts without the use of the 
microscope. Besides this, it can be used in any 
doctor’s office ■with a great deal of ease if the 
doctor is willing to take the blood and have an 
assistant read the sedimentation time every five 
minutes, or fifteen minutes. 

Dr. H. W. Kostmayer stated that he has had a 
limited experience with this test. He agreed with 
Dr. Sellers that the sedimentation rate is prob- 
ably the most valuable method we have of indi- 
cating the resistance of the patient, or, another 
way of stating it, the prognosis, and especially 
is it of value in determining the time to operate. 

Dr. William D. Phillips said that four or five 
years ago, when this sedimentation test was first 
suggested, he used it quite a bit in his service 
at Charity Hospital. At that time he had much 
trouble in securing the co-operation of the In- 
terne Staff. One great advantage of this test is 
the comparatively simple technic. Dr. Phillips dis- 
charged one of his patients the other day from 
this hospital with a sedimentation rate of over 
an hour. Accordingly, it would have been safe to 
operate. But there was one point he could not 
get away from. Dr. Phillips suggested, not as a 
discouragement of this sedimentation rate, but 
rather as a caution in using it, that we must not 
overlook the temperature chart. The patient 
that was discharged from this hospital the other 
day was not operated upon, even though the sedi- 
imentation test would indicate that operation was 
safe, because she continually ran temperature. 
Sometimes there is too much enthusiasm when 
using this test, and the temperature charts are 
overlooked. If this test is used with other scien- 
tific methods, it should be of great value. 

Dr. Edwin H. Lawson, in answer to a question, 
read the following excerpts from reprints: 

Gram found that the amount of fibrogen in- 
creased with a more rapid sedimentation rate. 

Fahraeus and Hober decided that the increase 
in agglutination of the erythrocytes was primarily 
due to a change in the electric tension between 
negatively charged erythrocytes and positively 
charged bodies in the plasma. 

Smiley explains the increase in the rate as 
due to an increase in the fibrogen and globulin 
with a relative decrease in the albumin content 
of the plasma. The above factors, hence, give 
an increase in the viscosity and diminution in sur- 
face tension of the plasma and in the erythrocytes, 
a diminution in the negative electrical charge 


144 


Hospital Staff Transactions 


with a change in the surface tension and an in- 
crease in the viscosity. He also noted that the 
temperature affected the rate as he found that 
the sedimentation rate was more rapid at incuba- 
tor temperature than at room temperature. 

Cooper found that as the cholesterol contents 
of the blood increase, the sedimentation rate be- 
comes more rapid. He also found that defibrin- 
ated blood gives a slower rate after defibrina- 
tion than previously. 

Rubin explained the rapidity of the rate as 
due to tissue destruction, and that the bacterial 
toxins, products of protein catabolism and inflam- 
matory products accelerate the rate; therefore, 
the more acute the condition, the more rapid the 
rate; the less virulent and numerous the bac- 
teria, the less variation of the rate from normal. 

In answer to another question, he said it has 
been his experience and it has been the findings 
of others that in cases of acute pyelitis there is 
a low sedimentation rate, as is the case in all 
acute inflammatory diseases. 

AN UNUSUAL CASE. 

Dr. H. W. Kostmayer presented a case that was 
very interesting to him because of the startling 
outcome. Mrs. P. A. H., aged 34, a mother of two 
children, had the last one ten years ago. She 
gave a history after child of ten years ago, of 
disturbed menstrauation profuse and prolonged 
uterine bleeding, and about eight months ago she 
began with a profuse discharge, more pronounced 
pain, finally having to take to bed. He made a 
diagnosis of pelvic inflammatory disease and put 
her to bed for six weeks with usual treatment 
of icebags and douches. She was then taken to 
the hospital, and, on admission, her leukocyte 
count was found to be 10,000. Thereafter, it 
was normal. Sedimentation time was most favor- 
able. There was a normal leukocyte count with 
some mobility in pelvis, which had been previously 
quite immobile. Her urine showed a few pus cells 
and faint trace of albumin. No phthalein test 
was done, as the kidneys did not interest him 
much. Dr. Kostmayer then operated on her, and, 
on entering the abdomen, through a midline inci- 
sion between the umbilicus and pubis, pelvic or- 
gans were found to be matted together with both 
large and small bowel adherent to them. The 
abdominal contents were walled off, and, after 
some tedious dissection because of bleeding, the 
pelvic organs were freed up and a supravaginal 
hysterectomy done. The adnexa were removed 
first because of bleeding, after which a suprava- 
ginal amputation of uterus was performed. A 
fairly good peritoneal toilet was secured, after 
which the appendix was sought. This was found 
to extend upward behind the cecum and a retro- 
grade operation was necessary for its removal. 
Cat gut ligature, linen purse string used, and 


cautery used for amputation. The abdomen wa 
closed with cat gut, reinforcing silk worm suture; 
and silk worm was used in skin. 

This patient was operated upon on Saturda 
morning and left the table in what was considere 
a very fair condition. Dr. Kostmayer was nc 
concerned about her condition at all, but on tb 
way down to the patient’s room, the anesthetis 
who accompanied the patient, noticed the puls 
had become rather weak. Dr. Kostmayer was in 
mediately notified of this and went to see he 
Patient was then infused. That night she hs 
become so much the picture of hemorrhage th; 
he feared something was loose in her abdome: 
She was given 450 c.c. of blood. She becarr 
somewhat better, but later, towards morning, si 
died. An autopsy was secured and the autops 
report showed an acute toxic nephritis, and fati 
degeneration of the liver. 

The startling thing about this case to Dr. Kos 
mayer is, that he considered this an absolute sa 
risk, and yet she died within twenty-four hou 
after operation. Incidentally, there was on 
about two drams of blood in the peritoneum ai 
the peritoneal toilet was good. There was i , 
surgical accident, and yet this woman of thirt i 
four years died. It was a startling shock, to s: ; 
the least. 

Dr. William D. Phillips asked what the fun I 
tional kidney test showed. He cited a case of 1 
of sometime ago, which impressed upon his miif 
the importance of paying very careful attenti 
to the urinary findings. A patient of his w 
brought into the hospital for plastic work and 1 
interne urged him not to take her at that tii 
as the blood examination showed some slig 
anemia and the urine examination was below n< 
mal. Dr. Phillips did not think this would gi 
any trouble and proceeded with the operatic j 
The patient died of acute nephritis. This incide^ 
has taught him a lesson and now when he has. 
case showing low functional kidney test or otb’ 
evidence of nephritis, he makes a more carei. 
investigation before proceeding with the operati<.< 

Dr. Thomas B. Sellers asked if it were possilij 
for a liver to change in that short time — pu-j 
tically twenty-four hours. These types of ca;i 
are worth a great deal to surgeons as th'j 
mean so much to them in trying to solve % 
problems they meet. ' 

Dr. Carroll W. Allen said that the rapidity f 
the development of the symptoms was startli 
and brings to mind a similar case. The pati t 
was a woman, treated about a year ago. 
was quite robust and in excellent health. A c -j 
lecystectomy was performed, the patient’s c 
dition was apparently very good for twelve r 
twenty-four hours, but still there was someth ? 


Hospital Staff Transactions 


145 


ibout her that caused some uneasiness. She died 
n about seventy-two hours. The autopsy report 
howed a fatty degeneraion of the liver. In this 
)articular case, all laboratory tests were run be- 
bre operation and were normal, the physical 
ondition was excellent, and yet this patient went 
lut with fatty degeneration of the liver from no 
issignable cause. 

Dr. Edwin H. Lawson said that in the case 
hat Dr. Allen referred to, a diagnosis of hepa- 
itis associated with alkalosis was made after a 
lonsideration of the symptoms of the case and 
he carbon dioxide combining power, which in this 
:ase was well above eighty. His attention was 
irst directed along these lines by Heyd of New 
fork, who clasified death following cholecystec- 
;omies into three classes; First: Those cases 

vhich have had previous operations on the gall 
dadder and which at the second operation, have 
lad drainage of the gall bladder with more or less 
nanipulation of the pancreas. Deaths in these 
:ases are possibly due to a pancreatic ferment or 
;oxin eliminated as a result of trauma of the pan- 
creas. Second; Cases which show acute yellow 
itrophy of the liver or portal cirrhosis and die 
!rom liver exhaustion. Third: Deaths due to he- 
latic insufficiency, which is associated with alka- 
osis. 

This case of Dr. Kostmayer’s appears to be a 
ieath due to some severe toxemia as is shown by 
;he destruction of the cells lining the tubules ol 
the kidneys and the acute toxic epinephritis. The 
ocation of the degeneration in the liver would 
suggest toxemia occurring somewhere along the 
tributaries of the portal vein. Associated with 
the above, such degeneration of the kidneys caused 
by toxins of either bacterial or chemical origin 
ind the sub-group of the latter would include 
the products of protein cleavage. While the death 
cannot be definitely and concisely ascribed to any 
cause, it is most probably due to the toxemia 
produced by the protein cleavage products. 

Dr. H. W. Kotmayer, in answer to Dr. Phillips, 
said the two pre-operative steps he did not take 
in this case were to have a phthalein test done 
and to have a chemical study of the blood made. 
Because of the excellent general health of the 
patient, her age, and a normal urinalysis, a phtha- 
lein test was not reconsidered. Coupled with a nor- 
mal temperature there was a slow sedimentation 
time. If there had been a delay of forty-eight 
hours or seventy-two hours following operation 
before she died, he could have understood that 
running a P. S. P. might have saved her life, if 
she had a poorly functioning kidney, but Dr. 
Kostmayer thinks no matter what the condition 
of her kidney, the failure of the organs of meta- 
bolism was primarily responsible. This case was 
either one of hemorrhage, which was doubted be- 


cause of the technic employed, or it v/as a case 
of complete collapse of the organs of metabolism. 
It seems her metabolic organs just stopped. The 
rapidity and abruptness of what seemed to be a 
safe risk completely disarmed and startled Dr. 
Kostmayer. 


THE PRESBYTERIAN HOSPITAL CLINICAL 
SOCIETY. 

The Society held its monthly meeting on the 
last Thursday of the month. The scientific pro- 
gram contained a discussion of several interest- 
ing cases and an interesting presentation of sev- 
eral interesting presentation by Dr. C. G. Cole 
on Polyposis of the Gastro-Intestinal Tract. Dr. 
Cole’s short but interesting paper was based oa 
personal experience with four such cases — the 
histories of which were presented — and a discus- 
sion of the various signs and symptoms which 
might lead to the diagnosis of these cases. He 
pointed out that the most usual type is the ade- 
noma. Lipomata, fibromata, and myomata have 
also been reported. The growths may be pedun- 
culated or sessile; and they may be submucous 
or subserous. 

According to the author polypoid adenomata 
of the gastro-intestinal tract is a rare condition. 
The clinical picture varies considerably; and a 
clinical diagnosis is most difficult. Very fre- 
quently the condition is only discovered at 
autopsy. Unless these tumors acquire a suffi- 
ciently large size they are rarely palpated. The 
fact is that they seldom become sufficiently large 
to be palpated. These growths may cause intus- 
susception, obstruction, or bring about a severe 
hemorrhage. Occasionally they may also undergo 
malignant degeneration. Rarely these tumors 
slough off and are passed per rectum. At times 
these tumors are only discovered at operation. 

Dr. Cole gave the case histories of four cases. 
They occurred in the stomach, small intestine, 
cecum, and sigmoid flexure. 

In the discussion, which followed. Dr. D. C. 
Browne stated that he has recently been able to 
collect only twenty-eight of these cases from the 
literature, in which the stomach was involved, 
and accepted Dr. Cole’s case as the twenty-ninth. 
He also brought out the fact that while the tu- 
mors are usually single in the stomach and the 
small intestine, the opposite is true for the large 
intestine. Their multiplicity in the large intes- 
tine makes treatment in this location very diffi- 
cult and unsatisfactory. 

A communication from the Board of Directors 
to the Staff expressed appreciation on the part 
of the former, for the confidence reposed in them. 
It was also brought out that the building program 


146 


Hospital Staff Transactions 


is being strictly adhered to and going along with- 
out interruption. This meeting was the last until 
the fall, when they will be resumed. 

FRANK L. LORIA, M. D. 


THE CHARITY HOSPITAL SURGICAL STAFF. 

Because of the hot summer months the regular 
meetings have been discontinued until the fall of 
the year. A case of unusual interest was reported 
at the last meeting by Dr. Alton Ochsner. This 
was a patient with cerebro-spinal rhinorrhea who 
made an uneventful recovery following an ex- 
ploratory craniotomy, and has remained well un- 
til the present. 

The patient was a woman thirty-six years of 
age, who three weeks before entry to the Charity 
Hospital, while getting out of bed noticed a pro- 
fuse discharge of clear serous fluid from one of 
her nostrils. This flow' was continuous up to the 
time of admission, when she was sent into the 
ear, nose, and throat service. Her complaint, in 
connection with this condition, was nausea caused 
by the salty taste of the secretion, as it ran back 
in the mouth and throat. There were also severe 
and persistent headaches — the latter, however, 
were not coincident with, but antedated the rhin- 
orrhea by six or eight months. 

Checking up the quantity of fluid discharged 
over a twenty-four hour period, measured at hourly 
intervals, some very interesting results were ob- 
tained. The amounts varied considerably, from 
5 c.c. to 70 c.c. per hour. It was clear, watery 
in character, and the discharge was most profuse 
after eating. She was observed over a period of 
several weeks during which time careful neuro- 
logical examinations were made. The neurologists 
found very little except for a diminution in cu- 
taneous sensation over the left side of the body, 
and a diminished left corneal reflex. Roentgen- 
ray of the skull showed a defect in the anterior 


cerebral fossa; and because of the symptoms, 
headache and apparent defect in the skull, it was 
thought she had a tumor of the anterior cerebral 
fossa. An exploratory craniotomy was done, ex- 
posing the anterior fossa of the right side ac- 
cording to the method of Cushing. The entire 
fossa was explored, but no pathology could be 
demonstrated. There were a few adhesions be- 
tween the dura and the floor of the anterior cere- 
bral fossa. Exploration was carried out as far 
back as the middel of the cerebral fossa, and 
from the median to the lateral portion of the 
skull. Since nothing could be found, and because 
of her headaches and increased pressure (18 mm. 
of mercury spinal fluid pressure) it was decided 
to do a decompression. The dura was left opened 
and the osteoplastic flap replaced. 

At first the patient did well, and had only a 
slight discharge from her nose. After the first 
day the rhinorrhea stopped. On the tenth day 
she had a headache. The spinal presure was 
found to be the same. Ten c.c. of fluid were re- 
moved. From that time she became free of head- 
ache; and until one week after discharge, when 
she was last heard from, there was no recurrence 
of the headache nor the rhinorrhea. 

What the condition was we are at a loss to 
say. The only explanation of the results obtained 
that we can give is that it was probably due to 
a plastic exudate resulting from the operative 
trauma, sealing the small fistulous opening which 
prevented the escape of fluid. What the ultimate 
result is going to be we are at a loss to say. The 
case is presented merely as an unusual one; and 
in which no pathology could be found. Dr. Gran- 
ger stated that the adhesions between the dura 
and the floor of the anterior cerebral fossa would 
have produced the same picture as that due to 
the tumor producing the erosion. No cause could 
be determined for the increased cerebro-spinal 
pressure. 

FRANK L. LORIA, M. D. 


ROUTINE CHOLECYSTOGRAPHY.— It would appear (1) 
that the routine application of cholecystography by the 
oral route is a very valuable procedure, accessible to any 
radiologist, and readily used with the routine gastro*intes« 
tinal patient, 

(2) That approximately one-half of the patients re- 
ferred for gastro-intestinal examination will show evidence 
of functionally disabled gall bladder. 

(3) That the positive evidence of gall bladder from 
oral cholecystography will be found as correct as any in- 
terpretation in the domain of radiology. 

(4) That the gall bladder which fails to outline (incon- 
clusive in this series) is usually, but not always, a path- 
ologic organ. 


(5) That a diseased gall baldder may function nor- 
mally, and that approximately 30 per cent of the patients 
proven by operation to have cholecystitis showed nornral 
function with the Graham dye test. 

It is possible that the demonstration of a normally 
functioning gall bladder in the presence of clinical symp- 
toms of cholecystitis may have value in clinical manage- 
ment. It is conceivable that a gall bladder which can 

still empty itself under the stimilus of food may be within 
the realm of medical treatment, as compared with one 

which is so functionally crippled that it can no longer 

empty within a reasonable time, and which, therefore, 

becomes a useless organ demanding surgical removal. — 
Watkins. W. W., and Mills, H. P., Radiology, 9:91, 1928. 


TRANSACTIONS OF ORLEANS PARISH MEDICAL SOCIETY 


During the past month the Society "has held 
its regular Board Meeting and the Second Quar- 
terly Executive Meeting. 

At the Quarterly Executive Meeting reports 
of the Special and Standing Committees were read. 
The following resolution presented by the Con- 
dolence Committee was adopted; 

Whereas, by the Will of God, Dr. Nathan Eisen- 
mann, our confrere, was taken from among us. 

Therefore, be it resolved. That this Society de- 
sires to express to the family of Dr. Eisenmann 
its regrets and sincere sympathy in its bereave- 
ment. 


The following members were elected to mem- 
bership : Active Members : Drs. J onas W . Rosen- 
thal, Seward H. Wills, Ralph C. Cross, F. J. 
Rohmer and Chas. S. Wood. Interne Members: 
Drs. M. W. Brown and E. L. Gill. 

Dr. J. A. Colclough was reinstated to Active 
Membership. 


One reference list on periotonsillar abscess has 
been prepared and added to the file. Fifty-four 
pamphlets have been catalogued and added to our 
collection. The shift allowed by our new shelving 
has been partially completed, greatly relieving 
the congestion of the shelves, and giving room 
for growth in the Journal files. The reference 
work has continued through the hot weather to a 
gratifying extent, calls for study in connection 
with particular case work being in the majority. 
This use of the Library in every-day practice is 
a most promising phase of the work, and such 
calls either in person or by telephone are given 
immediate attention. 


Gifts of Journals and reprints have been re- 
ceived from the following sources and have been 
gratefully acknowledged : 

Drs. Roy B. Harrison, E. D. Martin, I. I. 
Lemann, J. H. Musser, Arthur Weil, E. C. Sam- 
uel and the Cincinnati Medical Library. 


This executive meeting is the last meeting of 
the Society until October. 


It is with regret to report the death of Dr. 
H. S. Cocram, one of our honorary members. 


TREASURER’S REPORT. 

Actual Book Balance, 5/31/28 $1,492.62 

Receipts during June 1,175.80 


Expenditures 


2,668.42 

1,185.69 


Outstanding checks 


1,482.73 

195.04 


Receipts since Bank Balance 


1,677.77 

132.69 


Bank Balance - - $1,545.08 


LIBRARIAN’S REPORT. 

Forty-four books have been added to the 
Library during June. Of these 13 were received 
from the New Orleans Medical and Surgical 
Journal, 6 by subscription, 12 by binding, 2 by 
purchase and J1 by gift. ’ Note is made of new 
titles of recent date in the list herewith appended. 


NEW BOOKS. 

Coudry — Special Cytology. 2 v. 1928. 

Nelson’s Loose-Leaf Living Surgery, v. 5-6. 1928. 

N. Y. University and Bellevue Hospital Medical 
College — Collected reprints from the Depart- 
ment of Experimental Surgery. 1926-27-28. 

Louisiana State Board of Health— Sanitary Code. 
1928. 

Rockefeller Foundation — Methods and Problems 
of Medical Education. 1928. 

Borland — Ultra-violet Rays. 1928. 

Rivers — Filterable Viruses. 1928. 

Ross — Post-mortem Appearances. 1928. 

Tylecote — Diagnosis and Treatment in Diseases 
of the Lungs. 1927. 

Rehfuss — Diagnosis and Treatment of Diseases of 
the Stomach. 1927. 

Crisp, ed. — Ophthalmic Yearbook. 1927. 

Petty — Diabetes. 1926. 

Roster — Examination of Patients. 1928. 

Stewart — Compend of Pharmacy. 1928. 

Stitt — Practical Bacteriology, Blood Work and 
Parasitology. 1927. 

Jordan — General Bacteriology. 1928. 

H. Theodore Simon, 

Secretary. 


LOUISIANA STATE MEDICAL SOCIETY NEWS 

H. Theodore Simon, M. D., Associate Editor. 


MEETING OF THE SOUTHERN MEDICAL 
ASSOCIATION. 

Of interest to the members of the Louisiana 
State Medical Society is the approaching Twenty- 
second Annual Meeting of the Southern Medical 
Association. This meeting will be held in Ashe- 
ville, North Carolina, November 12-15. The 
Association selected for their meeting place one 
of the most magnificently beautiful spots in this 
United States, where a large number of good 
hotels are prepared and equipped to take care 
of many more than usually register at the Asso- 
ciation Meetings. 

The program commences on Monday, Novem- 
ber 12, with clinics arranged by the local pro- 
fession. In the morning these will be held at 
the Government Hospital at Oteen, the largest 
hospital for tuberculosis in the Veterans’ Bureau. 
Afternoon clinics will be held at the City Audi- 
torium, Asheville. On Tuesday there will be 
special clinics and demonstrations given by the 
leading practitioners of the South. The last two 
days of the meeting will be devoted to the scien- 
tific program of the seventeen sections. 

This Annual Meeting of the Southern Medical 
Association has become the second largest medi- 
cal meeting in the United iStates, the American 
Medical Association only surpassing it in num- 
ber of men in attendance. The Association meet- 
ing deserves all that it has accomplished and 
more. Every physician of the Society who could 
possibly get away to attend this getting together 
of Southern doctors should do so. The scientific 
program and the social activities insure an in- 
structive as well as a pleasant time. 


ST. TAMMANY PARISH MEDICAL SOCIETY. 

Meeting of St. Tammany Parish Medical So- 
ciety, July 13, 1928, at St. Tammany Hotel, 
Mandeville, La. 

Meeting called to order by the President, Dr. 
F. F. Young, with Secretary, Roland Young, at 
his post. On roll call the following answered : 
F. R. Singleton, J. F. Polk, J. K. Griffith, R. B. 
Paine and A. G. Maylie. Dr. Herrin, of Bush, 
La., was an invited guest and a prospective 
member. 

The President urged better attendance and com- 
plimented the iSlidell doctors on their regular 
attendance. 

The minutes of the meeting of May 11 and 
June 22 were read and adopted. 


Dr. Roland Young then gave a clinical case 
paper on tabes dorsalis complicated with an ar- 
thritis of the rim of the ilium between the an- 
terior and posterior iliac spines and of the third 
and fourth dorsal vertebrae as shown by radio- 
grams. Symptoms and treatment was brought 
forward in detail. This clinical case paper proved 
very interesting and discussions followed by Drs. 
Paine, F. F. Young, Sr., and J. K. Griffith. 

Dr. Paine, in citing clinical case discussions, 
mentioned a woman who was stabbed into abdo- 
men five nights ago with intestines protruding and 
told of his replacement of bowel and sewing up of 
wound. The case was then sent immediately to 
the hosiptal in New Orleans and said when last 
heard from that afternoon was still living. 

Communications were then read by the Secre- 
tary-Treasurer. One letter from the Secretary- 
Tieasurer of the State Society asked for an extra 
special tax of one dollar on each member as or- 
dered by the executive committee to defray un- 
usual expense of the committee of the State 
Medical Society on publicity and legislation. The 
Secretary was instructed to go ahead and get this 
money out to Dr. Talbot. 

Application to membership of Dr. Herrin, under 
unfinished business, was then in order and inves- 
tigating committee reported its approval of appli- 
cant. Vote was taken and there was no black- 
ball — all present voting. 

Roland Young, M. D., 
Secy-Treas. 


U. S. P. H. S. NOTES. 

Surgeon General G. W. McCoy has been ordered 
to proceed from Washington, D. C., to Carville, 
La., for conference relative to cases of leprosy. 

Assistant Surgeon (R) A. P. Rubino. Relieved 
from duty at Marine Hospital, New Orleans, La., 
on July 5, and assigned to duty at Marine Hos- 
pital, San Francisco, Calif. 

A. A. Surgeon C. P. Munday. Relieved from 
duty at Marine Hospital, New Orleans, La., and 
assigned to duty at Marine Hospital, Carville, La. 

Assistant Surgeon P. A. Neal. Relieved from 
duty at Marine Hospital, New Orleans, La., and 
assigned to duty at Marine Hospital, Mobile, Ala. 

Assistant Surgeon W. L. Barnes. Relieved 
from duty at Marine Hospital, New Orleans, La., 
and assigned to duty at Marine Hospital, San 
Francisco, Calif. 


Louisiana State Medical Society 


149 


Assistant Surgeon L. C. Watkins. Relieved 
from duty at Marine Hospital, New Orleans, La., 
and assigned to duty at Marine Hospital, Nor- 
folk, Va. 

Assistant Surgeon R. G. Townsend. Relieved 
from duty at Marine Hospital, New Orleans, La., 
and assigned to duty at Marine Hospital, Balti- 
more, Md. 

Surgeon (R) O. E. Denney. Directed to pro- 
ceed to Jacksonville, Fla., and other points in 
Florida, as may be necessary, to assist the State 
Health officer in making diagnosis of suspected 
lepers and to accompany patients diagnosed as 
lepers to Marine Hospital, Carville, La. 

Examination for candidates for commissions 
and assistant surgeons, U. S. P. H. iS., will be 
held at New Orleans, November 5, 1928. Requests 
for further information should be addressed to 
Surgeon-General of the U. S. P. H. S., Wash-- 
ington, D. C. 


The following assistant surgeons. Reserve 
Corps, United States Public Health Service, have 
been ordered to active duty and directed to New 
Orleans, La., Marine Hospital, effective June 28, 
1928: 

Drs. Jacques P. Gray, William F. Ossenfort, 
Kenneth R. Nelson, Joseph O. Dean, Herbert G. 
Brehm, Ivan W. Steele, Oswald F. Hedley, James 
W. Bryan, James T. Jackson, Walter P. Griffey, 
Vane M. Hoge, Raymond L. Evans, Russell S. 
Wolfe, Guy V. Gooding and Joseph W. Christie. 


SIXTH DISTRICT MEETING. 

The tenth annual spring meeting of the Sixth 
District Medical Society was held June 27th at 
Our Lady of the Lake Sanitarium, Baton Rouge, 
Louisiana: 

Dr. T. C. Paulson was elected president to suc- 
ceed Dr. A. G. Maylie. Dr. Guy Riche was elected 
vice-president. Dr. T. J. McHugh was elected 
secretary-treasurer, and Dr. Tom S. Jones as 
delegate to the Louisiana State Medical (Society 
meeting and the president as alternate. 

Drs. Wm. Scheppegrell and N. F. Thiberge pre- 
sented talks on Hay Fever and Asthma. The 
discussion of these papers was opened by Dr. 
J. A. Carruthers of Baton Rouge. 

A delicious luncheon was served by the hosts 
of the Sanitarium after which a Women’s Aux- 
iliary was formed. 

The scientific program of the afternoon was de- 
voted to the subject of Cancer of the Breast, the 
diagnostic, roentgenological, pathological and sur- 
gical point of view. 


Drs. R. G. McMahon, Lester Williams, T. Spec 
Jones and H. T. Nichole led the discussion. 

The entire day was voted a great success by 
the forty members of the organization who were 
present at the scientific and social programs of 
the day. 


At the regular semi-annual meeting of the 
Sixth District Medical Society, held at Baton 
Rouge, La., on June 27, 1928, this self-explana- 
tory resolution was unanimously adopted: 

“Whereas, the official list of Physicians, Sur- 
geons and Midwives, as published by the Lou- 
isiana State Board of Medical Examiners, con- 
tains no mark nor sign to differentiate between 
white and colored people, and. 

Whereas, said failure to differentiate is repug- 
nant and unsatisfactory to the members of this 
Society, as probably to the entire medical pro- 
fession of the (State of Louisiana, therefore, be it 

Resolved, That the Louisiana State Board of 
Medical Examiners be and is hereby earnestly re- 
quested to adopt some form, mark or sign to 
designate the whites from the colored people in 
the aforementioned list and that the attention of 
the Board be called to the American Medical Di- 
rectory published by the A. M. A., wherein the 
abbreviation ‘col.’ is used immediately following 
the names of colored people; and be it further 

Resolved, That the President of this Society be 
and is hereby directed to communicate these reso- 
lutions to the Louisiana State Board of Medical 
Examiners, forthwith.” 

Respectfully, 

A. G. Maylie, M. D., 

Past President, Sixth District Medical 
Society. 


At a meeting of the Third District Medical 
Society, held in St. Martinsville, La., June 28, 
Dr. H. W. E. Walther, of New Orleans, read a 
paper on the Modern Treatment of Gonorrhea. 


Dr. Charles J. Bloom, Professor of Pediatrics 
with the graduate school of medicine of the Tu- 
lane University of Louisiana, delivered an address 
to the Washington State Medical Society on June 
28, 1928, with Ileo Colitis as the subject. 


LOUISIANA STATE PEDIATRIC (SOCIETY 
The regular meeting was held at Baton Rouge, 
April 9, 1928, with L. R. DeBuys, M. D., presi- 
dent, in the chair. 

The question of continuing the organization 
was brought up and it was decided that there is 
a distinct place for such an organization as the 
Louisiana State Pediatric Society. The society 
then proceeded with the scientific program. 


150 


Louisiana State Medical Society. 


The first paper, Status Inversus Viscerum To- 
talis, was presented by Dr. DeBuys. It was dis- 
cussed by Drs. Naef and Signorelli. 

The second paper, A Translation of a Report 
Upon the Research in Relation to the Bacillus 
Calmette-Gerin, by Dr. A. Bocchimi of the Uni- 
versity of Perugia, Italy, read by Dr. Signorelli. 
It was discussed by Drs. Williams, Naef and 
DeBuys. 

The third paper was read by Dr. Williams on 
Food Edema. It was discussed by Drs. DeBuys, 
Naef and SignorelU. 

The fourth paper. Congenital Hemangioma, by 
Dr. Loeber, was read by title. 

The fifth paper. Ichthyosis, read by Dr. Naef. 
It was discussed by Drs. Signorelli and Williams. 

The society then went into its business session. 

A verbal report upon the society was made 
by the president. Dr. DeBuys, who gave reasons 
for its existence and suggestions for its devel- 
opment. 

There were no reports from committees. 

Because so few members were present, no nom- 
inating committee was appointed and it was 
decided to allow the members present to act as 
a committee. 

Under the head of new business, a resolution 
was presented as follows : “Because of adverse 

reports on experimental work conducted by sev- 
eral investigators, in connection with the Cal- 
mette anti-tuberculosis vaccine, also known as 
B. C. G. anti-tuberculosis vaccine, the Louisiana 
State Pediatric Society resolves; That the use 
of the B. C. G. anti-tuberculosis vaccine in the 
human be discouraged, until further positive evi- 
dence is obtained as to its efficiency and particu- 
larly as regards its harmlessness.” This was 
unanimously carried. It was decided that this 
resolution should be published in the New Orleans 
Medical and Surgical Journal. 

The next order of business was the nomination 
officers. 

Dr. Signorelli placed in nomination Dr. L. R. 
DeBuys as president for the ensuing year. This 
was duly seconded and a motion to close the 
nomination was made, seconded and carried. The 
election was unanimous. 

Dr. Williams nominated Dr. Emile Naef as 
vice-president. This was duly seconded and the 
same action as before was taken and Dr. Naef 
was unanimously elected as vice-president. 

Dr. Naef placed in nomination Dr. C. T. Wil- 
liams as secretary-treasurer. This was duly sec- 
onded and the same action as in the preceding 


instances was taken and Dr. Williams was unan- 
imously elected secretary-treasurer of the society. 

The following scientific committee was elected 
fcr the ensuing year: Dr. C. T. Williams, chair- 

man, and Dr. John Signorelli and Dr. Maud Loeber 
as the other members of the committee. 

The time and place for the next annual meet- 
ing, in accordance with the by-laws of the so- 
ciety, will be the same place and time as the 
meeting of the Louisiana State Medical Society, 
and will be held on the Monday of the week of 
their meeting. 

C. T. Williams, M. D., 
Secretary-T reasurer . 


RESOLUTIONS ON THE DEATH OF 
DR. L. C. TARLETON. 

Whereas, it has pleased the Almighty, on 
April 10, 1928, to remove from our midst one 
of the oldest and most highly respected members 
of the medical profession, the coroner of Avoy- 
elles Parish, useful citizen. Dr. Leo Chester 
Tarleton, and 

Whereas, in the death of this venerable gen- 
tleman, the medical fraternity, Avoyelles Parish 
and Louisiana, sustain the loss of a man whose 
loyalty to all classes and creeds was unswerving, 
the loss of a man who towered high in the esti- 
mation of those who value rectitude and who have 
a proper appreciation for the lofty attributes 
which makes the private and public career, such 
as that of Dr. Tarelton, honorable and beautiful, 
therefore be it 

Resolved, That the Avoyelles Parish Medical 
Society, whose privilege and honor it has enjoyed 
with the affiliation and co-operation of so val- 
uable a member — an active member for many, 
many years, an honorary member for the last few 
years — wishes to chronicle the death of a brother 
physician whose life has been an unbroken chain 
of religious, charitable and industrial perform- 
ance,and whose noble deeds of professional ethics 
and kindness to all serve as a beacon light to 
posterity, therefore, be it further 

Resolved, we extend the Society’s sincerest con- 
dolences to his sorrowing widow and interesting 
family and that a copy of these resolutions be 
sent to them, a copy for publication in the New 
Orleans Surgical and Medical Journal, and a copy 
spread with our minutes as a permanent record. 

Walter F. Couvillion, 
Sylvan de Nux, 

S. J. Couvillion, 

Committee. 


MISSISSIPPI STATE MEDICAL ASSOCIATION NEWS 


J. S. Ullman, M. D., 

FACTORY INSPECTOR. 

Believing that the State Board of Health has 
an opportunity to do a far greater service for 
the people of the state, especially the men, women 
and children who are working in the factories in 
ever increasing numbers, by inaugurating a great 
health program for the protection of the workers 
our aim being to do everything possible for the 
promotion of the health, contentment, and happi- 
ness of the workers which will not only be a 
splendid service to these people but will also be 
profitable from a financial standpoint to the 
stockholders and owners of the various enter- 
prises coming under the enforcement of child labor 
laws — and, because the Legislature has placed 
the responsibility for the administration of the 
act in the hands of the State Board of Health 
(“The State Board of Health shall appoint and 
may remove for caxse a sp>ecial inspector who 
shall have the title of factory inspector and who 
shall be a person having competent knowledge of 
factories and capable of performing the duties 
prescribed below”; “said inspector shall report 
annually to the secretary of the State Board of 
Health,” etc.), we propose to carry on the work 
of the department according to Chapter 163, Laws 
of 1914, and in addition adopt the following 
course and program: 

1. This department shall be considered the 
Bureau of Industrial Hygiene of the State Board 
of Health. 

2. The factory inspector shall be a physician 
well trained in public health. 

3. A woman assistant in the person of a well- 
trained public health nurse shall be assigned to 
the Bureau of Industrial Hygiene for at least six 
months during the year, or for nine or even 
twelve months if the work demands. 

4. The factory inspector shall carry out a con- 
structive program, during the summer months at 
least, in preventive dentistry — this to be done by 
the use of two or more mouth hygienists between 
school terms. Where deemed advisable these 
mouth hygienists can arrange a corrective pro- 
gram through the local dental society. 

5. In addition to his other regular duties, the 
factory inspector and the nurse shall be held re- 
sponsible for the physical inspection, follow-up 
work in the homes, and for health educational 
work, such as moving pictures, lectures, and the 
distribution of literature, also vaccinations and 
immunizations in all counties not having a full- 
time health department. The work is to be done 
in co-operation with the part-time health officer 
and factory physician. 


Associate Editor. 

6. In addition to reports required by Chapter 
163, Laws of 1914, the state factory inspector 
shall make a monthly report of all his public 
health activities direct to the state health officer 
upon a form furnished him for the purpose. Tll§ 
public health nurse shall make monthly reports to 
the supervisor of public health nursing as the 
other public health nurses in the state. Her re- 
port is to be approved and signed by the state 
factory inspector. The mouth hygienists’ reports 
will be made to the supervisor of mouth hygiene, 
State Board of Health, said reports to be approved 
and signed by the factory inspector. The inspec- 
tor shall do his own work and in addition direct 
the work of the nurse and mouth hygienists. 

Requests by the factory inspector for specialized 
services in work -with crippled children, in tuber- 
culosis, nutrition, and feebleminded, and other 
problems of a public health nature will receive 
immediate attention and everything possible done 
to promptly supply the need. Institutions and 
agencies doing these different phases of work will 
co-operate in a splendid way to bring about the 
best results. 

This program will be put into effect July 1st 
when a public health nurse and oral hygienist 
will be assigned to the factory inspector. 

It is the sense of the Board that no election 
of factory inspector should be made until the 
October meeting of the Board, and that the 
present incumbent. Dr. R. S. Curry, continue to 
serve until the matter is finally disposed of by 
the Board at that time. 


Dr. E. W. Holmes, who was graduated by 
Tulane University in June, and was licensed by 
the State Board of Health at its recent session, 
is now located in Winona, Mississippi. He is 
associated with his brother. Dr. T. W. Holmes, 
who is in charge of the Winona Infirmary. 


The Vicksburg Sanitarium held its staff meet- 
ing on July 11, 1928. Its scientific program was: 

1. Rupture of Right Ovary with Intra-abdom- 
inal Hemorrhage, Dr. G. M. Street. 

2. Ulcer of the Duodenum with Chronic Per- 
foration, Dr. A. Street. 

3. Fracture of the Os Calcis, with X-ray 
Studies, Dr. J. A. K. Birchett, Jr. 

4. Aneurism, Probably of the Arch of the 
Aorta, Dr. L. J. Clark. 

5. Tuberculosis of the Maxillary Sinus, Dr. 
E. H. Jones. 

On July 12 the Homochitto Valley Medical So- 
ciety held its regular quarterly meeting in Nat- 
chez. In the absence of the president the chair 


152 


Mississippi State Medical Association 


Dr. John H. Musser, professor of medicine at 
was occupied by Vice-President E. E. Benoist. 
Tulane University, presented a paper on the sub- 
ject of Euphyllin in the Treatment of Heart 
Disease. 

Dr. J. S. Ullman reported a case of varicose 
veins treated by injections of sodium salicylate. 

Another interesting feature of the meeting was 
a round table discussion of therapeutic measures. 

The next regular meeting of the Homochitto 
Volley Medical Society will be held in October at 
which time officers for the ensuing year will be 
elected. 


Dr. L. H. Lamkin of Natchez is confined to his 
bed on account of an attack of erysipelas. 


Dr. and Mrs. Philip Beekman of Natchez are 
spending their vacation in Atlantic City. 


The regular meeting of the Issaquena-Sharkey- 
Warren Counties Medical Society was held in 
Vicksburg on July 10, at which time the entire 
program was devoted to the subject of Tuber- 
culosis. 

The moving picture film. The Doctor Decides, 
was shown. This film was prepared by the 
American Child Health Organization and stresses 
the importance and methods of early diagnosis in 
tuberculosis. 


The following physicians have recently settled 
in Vicksburg: Dr. J. M. Feder at the Vicksburg 

Infirmary; Dr. Hugh H. Johnston at the Vicks- 
burg Sanitarium; Drs. Frank E. Werkheiser, Rex 
Goodman and H. C. Dillworth at the Mississippi 
State Charity Hospital. 


The following compose the staff of the South 
Mississippi Charity Hospital, Laurel, Mississippi: 
Dr. R. H. Foster, superintendent; Dr. C. J. Lewis, 
assistant superintendent; Drs. J. R. Johnson and 
E. S. Roberts, house physicians. 

The following medical students are here attend- 
ing the clinics during the summer: J. W. Vaughn, 
Emory University; Hubert Flurry, University of 
Pennsylvania, and W. B. Hickman, Tulane 
University. 


The correspondence given below shows again, 
v/ithout need of any further comment, the harm 
that the negro quack, Redmon, is doing. This 
seems to be another instance of the will- 
ingness of our courts to consider techni- 
calities in the interpretation of the law 
rather than consider the public welfare. During 
the months that the State Board of Health 
has been restrained from putting a stop to the 
activities of this charlatan, many a poor sufferer 
from tuberculosis, cancer, or other equally serious 
conditions is wasting valuable time. It is a ques- 


tion, when we consider the dilatory methods of 
the courts in questions of public health and pub- 
lic welfare, whether the harm done by the loss 
of time should not be placed on the shoulders of 
the courts rather than on the shoulders of the 
quack. 

Franklinton, La. 

June 18, 1928. 

Dr. F. J. Underwood, 

State Health Officer, 

Jackson, Mississippi, 

Dear Doctor Underwood: 

Has your office any information on the matter 
of Henry Redmond, negro, from Bogalusa, La., 
practicing medicine in Mississippi without license? 

It seems that this negro makes medicine, and 
sells it in Mississippi, a few miles off in the coun- 
try from the line of Louisiana. We thought he 
practiced also in Bogalusa, but the police say 
they can find no instance of such practice here. 
I understand he is doing a “land office” business, 
buying property in Bogalusa and seems to be 
prosperous. It is said whites and blacks go to 
him for many miles and it is said that there are 
instances of long waits for your turn to get a 
consultation and some of the miraculous medicine. 

If you have any information on this matter to 
impart to us we will gladly receive it for con- 
sideration at our medical society. Our committee 
presented names of supposed patients to the 
police, but they say he does not treat here but re- 
quires all to go to his rendezvous in Mississippi. 

Thanking you for any information you can let 
me have on this matter, I remain, with best 
wishes. 

Fraternally yours, 

John Schreiber, Secretary, 
Washington Parish Medical Society. 

Dr. John Schreiber, Secretary, Jackson, Miss. 
Washington Parish Medical So- June 19, 1928. 

ciety, Franklinton, La. 

Dear Doctor Schreiber: 

The negro Redmond was tried before Chan- 
cellor Dale last October and perpetually enjoined 
from dispensing his concoctions. Messrs. Sharp 
and Cassedy, representing the Attorney General’s 
office, worked up the case and tried it with the 
results mentioned above. 

Later, a member of the Supreme Court of 
Mississippi, Judge Ethridge, modified the injunc- 
tion, which in effect permitted the negro to re- 
sume his luci-aUve practice. The negro has ap- 
pealed his case to the Supreme Court. I sincerely 
hope that the case will receive the attention of 
said Court at an early date and that when the 
case is tried before the Supreme Court, the result 
will not justify Mississippi in being the laughing 
stock of Louisiana, Alabama, and- Tennessee any 
longer in matters of this kind. 


Mississivvi State Medical Association 


153 


When the case is tried, I shall send you a copy 
of the decision which you may present to your 
medical society. 

Very truly yours, 

Felix J. Underwoodl 


Hon. Rush H. Knox, Jackson, Miss. 

Attorney General, June 19, 1928. 

Jackson, Miss. 

Dear General Knox; 

I am enclosing- copy of letter from Dr. Hchrei- 
ber. Secretary, of the Washington Parish Medi- 
cal Society, Franklinton, La., which is self- 
explanatory. 

You see this negro knows better than to at- 
tempt to practice in Louisiana; he has his Lou- 
isiana patients come over into Mississippi where 
he prescribes for them and where he is, so far, 
immune to the law. 

Would it not be possible to get his case before 
the Supreme Court at an early date in order to 
get him out of Mississippi? I know that your 
office has been doing everything possible and that 
but for that fact that Judge Ethridge modified 
the injunction, he would not now be in Mississippi 
violating our laws and obtaining money under 
false pretenses daily. 

It will soon be a year since Chancellor Dale 
tried this negro quack. Right thinking people in 
this state, and there are many of them now, in 
the territory in which this negro operates think 
that it is an outrage to longer permit the state 
to place a premium on ignorance and superstition. 

He is selling his concoctions in Philadelphia and 
a number of other places through other negroes 
and numerous complaints are coming in daily 
from places where Redmond is operating through 
other people. 

Thanking you for your continued interest in 
the case, I am, with best wishes. 

Very truly yours, 

Felix J. Underwood. 

Judge George H. Ethridge, Jackson, Miss. 

Jackson, Miss. June 19, 1928. 

Dear Judge Ethridge: 

I am enclosing copy of letter received from Dr. 
John Schreiber, Secretary of the Washington 
Parish Medical Society, Franklinton, La., which 
is self-explanatory. I have received numerous let- 
ters of this kind from Louisiana and Alabama, 
to say nothing of those received from different 
parts of Mississippi. 

I am not inclined to blame you for undoing the 
good work of Chancellor Dale because, knowing 
you as I do, I have absolute confidence in your 
integrity and do not believe that you would do 
anything that is not in accordance with the law, 
but I do think it was most unfortunate and I hope 
that the case will come before the Supreme Court 
at an early date and that the facts presented by 


the Attorney General’s Office and the State Board 
of Health from the record may justify the Court 
in sustaining Chancellor Dale’s decision. 

Again, I wish to express my confidence in you 
and to again say that I am not disposed to blame 
you, but simply feel that it was most unfortu- 
nate that this negro should be permitted to con- 
tinue his practice, not only himself, but through 
at least a dozen other negroes in different parts 
of the state. 

Very truly yours, 

Felix J. Underwood. 


PATIENTS IN MISSISSIPPI STATE HOS- 
PITALS FOR MENTAL DISEASE: 1927. 

The Department of Commerce makes the fol- 
lowing announcement concerning results of the 
1927 census of mental patients in the two state 
hospitals of Mississippi: 

These hospitals had a total of 1,056 first ad- 
missions during the year 1927, as compared with 
1,008 in 1926, and 922 in 1922. 

These first admissions represent patients re- 
ceived during the year, who had not previously 
been under treatment in any hospital for mental 
disease. Such newly admitted patients afford the 
best available measure of the number of new 
cases of mental disease which are brought under 
hospital treatment during a given year. 

The increase in the number of first admissions 
to state hospitals in Mississippi between 1922 and 
1927 was relatively greater than the growth in 
the State s population during the same period, as 
shown by the fact that the first admissions in 1927 
numbered 59 per 100,000 of population as com- 
pared with 56.3 in 1926, and 51.5 in 1922. 

The extent to which provision has been made 
for state treatment of mental patients is indi- 
cated by the number of patients present in the 
state hospitals on a given date. In Mississippi, 
the number of mental patients under treatment in 
the state hospitals has increased steadily from 
1,978 on Jan. 1, 1910, to 2,990 on Jan. 1, 1928; 
and the ratio of such patients per 100,000 of 
general population increased from 110.1 on Jan. 
1, 1910, to 167 on Jan. 1, 1928. 

Of the first admissions in Mississippi during the 
year 1927, 633 were males, and 423 were females; 
arid of the patients present on Jan. 1, 1928, 1,393 
were males, and 1,597 were females. 

These figures are based on reports furnished 
by the institutions. The figures for 1927 and 1928 
aie pieliminary and subject to correction. 


- 2,990 167.0 

1927 1,056 59.0 2,854 159.4 

1928 1,008 56.3 2,727 152.3 

1923 2,537 141.7 

1923 922 51.5 2,510 140.2 

1910 1,978 110.1 


BOOK REVIEWS 


Gynecology: By William P. Graves, A. B„ M. D. 

Fourth edition, thoroughly revised. Phila- 
delphia and London, W. B. Saunders Co. 

1928. pp. 1016, with 562 illustrations, 128 in 

colors. 

The amazingly rapid progress of the specialty 
of gynecology is in no way better illustrated than 
by the fact that within five years of the publica- 
tion of the last edition of Graves’ Gynecology, a 
new revision is necessary, or rather a new book, 
for this edition is considerably more than a revi- 
sion. It is typical of the lines along which this 
specialty is advancing that whereas the section 
dealing with operative gynecology is changed only 
in comparatively unimportant details, the sections 
dealing with pelvic pathology show very extensive 
changes, and the section dealing with physiology 
is practically new. This corroborates the opinion 
of many observers, that surgery, in matters of 
technique and performance, has almost reached its 
inevitable limits, whereas, thanks to the patient 
work of tireless students in the fields of physiol- 
ogy, pathology and biochemistry, the conception 
of medical science is still in a state of flux, and 
even more radical changes are to be expected 
than have already occurred. 

The Gynecology is a monumental reference 
work, more complete in every respect than any 
similar text of which the reviewer has knowledge. 
For such an encyclopedia of gynecology there is, 
of course, a very real need. On the other hand, 
the remarkable completeness of detail in a way 
does the book a disservice, for in the very multi- 
plicity of facts there is sometimes a loss of per- 
spective. Then, as is unfortunately more and 
more true of medical works, the mere size of the 
volume deters the reader. More than eighty 
pages have been added to the text, and the illus- 
trations— which, by the way, are of a uniform 
standard of excellence — have also been added to, 
so that the bulk of the work has been very ma- 
terially increased. Such a complaint is, of course, 
a trivial one, and of small import in the face 
of the general excellence of the presentation, 
but one does wish that there could be some limit 
to the increasing size and weight of medical texts. 

One cannot fail to be impressed with the tre- 
mendous labor which this revision has evidently 
involved. The mere review of the literature, 
v/hich is carried up to the date of publication, 
must have been an enormous task in itself, quite 
aside from the literary labor necessary to produce 
a book of this extent. To mention specific changes, 
the whole section on the physiology of the pelvic 
organs has been revrritten, and new material has 
been added relative to the physiology of the va- 
gina and the fallopian tubes. The section on en- 


docrinology is practically new and includes all 
of the recent valuable work of tke Continental 
investigators, as well as of Robert Frank, Emil 
Novak and their co-workers. The same review of 
this particular subject is especially refreshing 
in the midst of the confused and exaggerated 
claims which the very mention of the glands of 
internal secretion so often produces. Endocervi- 
cites is presented in a new and more complete 
way, and the reviewer has nowhere seen a clearer 
presentation of the confused and overlapping sub- 
jects of kraurosis and leukoplakia of the vulva. 
The classifications of vulvitis, vaginitis and endo- 
metritis have been improved, but one notes, with 
regret, that oophoritis is still a vague and highly 
speculative subject. The sections on gynecologic 
tumors have been completely rewritten, and de- 
scriptions of many new and rare tumors have 
been added. It is unfortunate that these latter 
growths cannot be accorded a less striking pre- 
sentation— possibly by some mechanical arrange- 
ment of type — so that the greater importance of 
the more common tumors might be emphasized. 
A new classification of ovarian tumors is advanced, 
based on new theories of histogenesis, which is 
decidedly clearer and more logical than the old 
Pfannenstiel grouping, though, as the author him- 
self frankly acknowledges, it is still far from sat- 
isfactory. The section on endometriosis, which is 
entirely new, is the most comprehensive and 
valuable critique of this subject which the re- 
viewer has seen, and the bibliography is very com- 
plete. The whole section on sterility has been re- 
written, and the etiology and treatment of this I 
increasingly important subject have been brought 
absolutely up to date. In the line of therapy 
all of the new methods of treatment are included 
protein therapy, diathermy, irradiation for amen- 
orrhea and sterility, etc., and the employment o'’ 
radium in carcinoma of the cervix according t< 
the ideas of the French School is discussed a 
considerable length. 


The inclusion in the text of collective statis 
tical studies of certain clinical entities is a par 
ticularly good departure, for it has long been th' 
reviewer’s opinion that this method is the mos 
accurate way, at least from the clinical stand 
point, to appraise any given disease and its treat 
ment. Also noteworthy is the fairness of th 
author’s presentation. Naturally the entire sut 
ject matter is colored by his own vast clinical eJ 
perience, but he is careful always, where mattei 
of nrincinle are involved, to quote the opinior 


and practice of others also. 

A very striking feature of this new edition 
the detailed consideration of cancer, particular 
from the standpoints of etiology and prophylax) 
Whether the author is correct in assigning t 


Book Reviews 


155 


heredity the importance which he apparently is 
inclined to give to it is still a matter of debate. 
Fut certainly there can be no question as to the 
con’ectness of his emphasis on chronic irritation 
as a chief causative factor, and his correlation 
of such various predisposing causes as lesions of 
the vulva and vagina, endocervitis, uncorrected 
childbirth injuries, gynatresia and uterine fibroids 
with the later occurrence of malignancy, is entirely 
to be commended. 

The arrangement of the subject matter is for 
the most part quite logical, but the reviewer won- 
ders, as he has wondered in reading former edi- 
tions, what possible basis there is for the chap- 
ter entitled “Special gynecologic diseases.” The 
place of ectopic pregnancy is always a disputed 
one, but amenorrhea, menorrhagia, sterility, even 
dysmenorrhea in most of its manifestations are 
symptoms, not diseases, as the author himself is 
careful to emphasize, and for that reason it js 
misleading to deal with them under the above 
heading. Would not a section entitled “Disorders 
of function” be more logical? Moreover, “Ra- 
dium in the treatment of non-malignant gyne- 
cologic disease” is a therapeutic consideration, 
and as such most emphatically does not belong 
among “Special gynecologic diseases.” 

On the whole, however, this book is deserving 
only of the highest praise. It is a complete, im- 
partial, scholarly presentation of one of the most 
important divisions of medical science, and it can- 
not fail to add fresh laurels to the already con- 
siderable fame of its clinician-author. 

C. Jeff Miller, M. D. 


A Manual of Otology: By Gorham Bacon, M. D., 
F. A. C. S., and Truman Lawrence Saunders, 
M. D., A. B., F. A. C. S. Eighth edition. 

Philadelphia, Lea & Febiger. 1928. pp. 576. 

It has been said that it is easier to write a big 
text book than a small one, the author of the 
small text book having carefully to condense ma- 
terial while the writer of the large book is at 
liberty to expand and reiterate. This book being 
of 560 pages falls in the class of small text books. 
It was intended by the author that the book be 
a compact book of reference for the busy general 
practitioner and a text book for students. The 
subject matter is condensed, readable and for the 
size of the book quite comprehensive. Technique 
of operations on the nose and throat has been 
omitted in this edition although the discussion of 
diseases of the nose and throat in their relation 
to ear troubles is of course, continued. 

H. Kearney, M. D. 


Brain and Mind or the Nervous System of Man: 

By R. J. A. Berry, M. D., F. D. C. S., F. R. S. 

Edin, New York, Macmillan Company. 1928. 

pp. 608. 

This volume represents the indefatigable and 
painstaking application of the author. It is a 
compilation of embryology, anatomy, physiology, 
biology and neuro-psychiatry. Much of this is 
given to neuro-anatomy with explanatory data of 
the brain and spinal cord. To a large extent it 
is evolutionary in description. 

Chapters 29 and 30 deal with problems most 
instructive. Chapter 35 elaborates on the signifi- 
cance of the nervous system in an explanatory 
manner which is seldom met with in writings of 
this type. The chapter on Sleep, Dreams and 
Emotions is well written and shorn of all pseudo 
interpretations as to their happenings. The para- 
graph therein concerning fatigue and sleep is 
well worth reading. 

The remaining chapters with illustrative clin- 
ical cases deal with amentia, a matter of vital 
interest to our civilization and is markedly 
eugenic in character. 

The author is a neuro-psychiatrist of note and 
has placed within a volume intelligently written 
the results of his personal activities, investiga- 
tion and research as only one who has closely 
contacted the subject matter therein dealt with. 

Walter J. Otis, M. D. 


Strabismus: Its Etiology and Treatment: By 
Oscar Wilkinson, A. M., M. D., D. Sc. St. 
Louis, C. V. Mosby Co. 1927. pp. 240. 

Ophthalmology is indebted to the author for an 
interesting and instructive volume about a sub- 
ject which needs much intelligently understanding 
by the oculist, the general physician, and the 
public. Many popular conceptions on crossed eyes 
are hopelessly incorrect and would be humorous 
if they did not result in a deformity which handi- 
caps a human being through life and always rep- 
resents a souvenir of someone’s ignorance. 

The reader is given an unusual versatility of 
opinion, no previous volume having more exten- 
sively quoted the literature on this subject. The 
author’s individual ideas and conceptions however 
are very well expressed and represent the ma- 
ture judgment of the experienced clinician. 

The first section gives an entertaining histori- 
cal review, showing that m"any of our current 
and supposedly new ideas about strabismus are 
in reality, a hundred or more years old. They 
have been re-bom every few years and most of 
the deliveries have been dry labors. Thus, the 
conceptions of correcting squint by glasses, by 


156 


Book Reviews 


operation, and of improving sight in certain 
cases by exercise, are at least a hundred and 
fifty years old — that we know of. 

The various theories of strabismus with their 
proponents and opponents are elaborately dis- 
cussed and cussed. The muscular theory assumes 
that strabismus is essentially due to a faulty me- 
chanical alignment of one or more parts of the 
orbital contents, while the accommodative theory 
regards the equalization of accommodation and 
convergence as the vital factor. The fusion the- 
ory assumes the inability of the central visual 
motor mechanism to properly direct the eyes to- 
gether as the essential cause, while the nervous 
theory maintains that our nervous vitality is the 
deciding factor in keeping the eyes in their nor- 
mal direction. In reality, all of these theories are 
right; and all are wrong. No single cause is 
alone responsible for all crossed eyes. Three 
variable factors, individually or together, are in- 
volved in all strabismus. They are,— the eyeball, 
the mechanical alignment of the orbital contents, 
and the motor visual brain function. If these do 
not work properly and together, keeping the eyes 
straight becomes more and more difficult. Finally 
a point is reached when the proper fixation of both 
eyes becomes impossible; and, in, or out usually, 
goes one eye or the other. This usually occurs 
during excessive fatigue, or its equivalent, low- 
ered bodily vitality. 

The anatomy of the orbit and ocular muscles 
as well as their physiology, is taken up at some 
length, also the types and measurements of stra- 
bismus, These sections are interestingly written 
but do not contain a great deal that is really new, 
largely because little worth while has recently 
been advanced on these subjects. 

The examination of the patient with strabis- 
mus is then described, a chapter which will espe- 
cially appeal to those who have not worked out 
the examination technic best adapted to their 
individual needs. Each of us is inclined to think 
that our way of doing things is best — and for 
us it often is. 

About eventy-five per cent of persons with 
squinting eyes can be practically cured of their 
deformity without operation if taken in charge 
early enough by an ophthalmologist who really 
understand and is interested in this subject — 
incidentally quite a few are apparently not. The 
most difficult problem is the constant adaptation 
of treatment to the patient’s individual and cur- 
rent needs. As the author mentions, orthoptic 
exercises, which are a valuable adjunct to refrac- 
tion, should not be continued after they have 
ceased to be of practical benefit. Only one case 
in about ten obtains permanent benefit from ocu- 
lar exercises because the doctor, the patient and 


the parent will not continue their use in a regular, 
systematic and intelligent way. 

All of the accepted methods of operative treat- 
ment are decribed in detail, in fact it is possible 
that the author has discussed too many rather 
than too few operations. It is so easy for the 
younger ophthalmologist to get lost in a mass of 
different operations and make a mistake in the 
practical solution of the individual problem be- 
fore him. Dr. Wilkinson has perfected the oper- 
ation of resection and has invented several in- 
genious instruments which make it the simplest 
and most accurate of the strengthening types of 
operation. 

The volume closes with photographs and de- 
scriptions of illustrated cases and a carefully il- 
lustrated index. 

The author in this very practical volume insists 
justly and often that many of the failures in 
the non-operative treatment of strabismus are 
due to negligence on the part of the parents or 
the oculist. He also urges the use of orthoptic 
exercises after operation, an important point 
which is not usually seen in print. His state- 
ment that tenotomy should never be done on 
children under twelve years of age seems rather 
dogmatic, notwithstanding that this operation has 
been greatly abused in by-gone years. Anyone 
who is really interested in this subject will do 
well to read Dr. Wilkinson’s book; and then read 
it again. 

Charles A. Bahn, M. D. 


The Diagnosis and Treatment of Diseases of the 
Stomach: By Martin E. Rehfuss, M. D. 

Philadelphia, W. B. Saunders Company. 1927. 
pp. 1219. 

This is a very excellent volume, for several 
reasons: 

The subject matter is interesting and attrac- 
tively presented. 

A special chapter is devoted to “The study of 
food digestion in the stomach.’’ This chapter 
covers the action of a large number of food- 
stuffs in the stomach, particularly with relation 
to their effect in stimulating gastric secretion 
and also the time required for their evacuation 
from the stomach. It is but a short step to apply 
the knowledge, so gained, to disease processes 
and this Dr. Rehfuss does when discussing vari- 
ous gastric conditions. 

Many chapters are devoted to the relationship 
existing between the stomach and other organs, 
particularly the duodenum, gall-bladder, pancreas, 
colon and appendix. This, in the opinion of the 
reviewer, is a very excellent plan as gastric func- 


Book Reviews 


157 


tions are so intimately associated with the other 
viscera, particularly those supplied by the vago- 
sympathetic nervous system. 

While about everything which can have a bear- 
ing upon gastric function has been discussed in 
this work, the reviewer feels that a short chapter 
devoted to a discussion of that common ailment 
Indigestion ’ and its common causes, would have 
fitted in nicely. 

This volume is most heartily recommended for 
its completeness and the excellent presentation of 
the subject matter. 

J. Holmes Smith, Jr. 


Nurses, Patients and Pocketbooks: Report of a 
Study of the Economics of Nursing Con- 
ducted by the Committee on the Grading of 
Nursery Schools: By May Ayres Burgess, 

Director. New York, N. Y. 1928. pp. 618. 

Nurses, Patients, and Pocketbooks is a report 
on more than a year’s nation-wide study of the 
supply and demand in nursing service conducted 
by the Grading Committee of Nursing Schools. 

The Grading Committee, having been created 
by seven national organizations, felt that they 
could not set any standard of education until they 
thoroughly understood conditions. Thus a sys- 
tem of questionaires sent to physicians, nurses, 
patients, public health supervisors, institutional 
supervisors and registrars have been used in com- 
piling statistics on the economic situation. Miss 
Burgess has endeavored to present these facts 
not only in the form of percentages and diagrams 
but by the actual words used by many individuals. 


That there is no shortage of nurses is shown by 
the fact that many parts of the country report 
serious conditions of unemployment. There are 
more than two nurses to every doctor now, and 
It was shown (by a series of computations) that 
unless something is done, in another thirty years 
there will be ten to one. Will the public use this 
many nurses? 

Of the different branches of services, the private 
duty nurses were the most discontented. There 
IS evidence to show that they are the poorest paid, 
have the longest hours, have less recreation, have 
less social life, have more sickness, and receive 
the least sympathy and understanding. 

Some patients and many doctors complained of 
the expense the nurse carried. About one out of 
every three, reported on by physicians, found it 
harder to pay the nurse than to get a good one. 
Many patients expressed their interests in hourly 
or group nursing which would be less expensive 
for the patient, and necessitate shorter hours for 
the nurse than under the present system. 

Patients were more critical of nurses than phy- 
sicians, but it was shown that the majority of 
physicians and patients prefer trained nurses; and 
by far the largest per cent say they would employ 
the same nurse again. Some serious criticisms 
were made, most of which were that the nurses 
lack the proper background of training and edu- 
cation; some nurses were very thoughtless of the 
family and existing conditions. Statistics show 
that half of the graduate nurses have had four 
years of high school, and that 15 per cent have 
had one year or more of college. The remaining 
35 per cent have had less than four years of high 


The outstanding fact presented is that nursing 
training schools are the only schools conducted 
on a truly economic basis. They exist because the 
hospital needs skillful, docile labor at the lowest 
possible cost. There are a few exceptions in the 
University Training Schools, but these are rare. 
As the nursing service in most hospitals is inade- 
quate the patient must, if he needs special atten- 
tion, employ a private nurse. No effort is made 
to give the public the benefit of the trained 
worker. Even when professionals are employed 
on floor duty, they often supplement the student 
rather than taking charge of her training. Again 
no special preparation is made for the branch of 
service a nurse expects to do after graduation, 
and because many hospitals need students they 
admit girls who although they may do fairly well 
under strict supervision are not desirable after 
graduation. Fifty-four per cent of the graduate 
nurses do private duty, 23 per cent institutional 
work, 19 per cent Public Health, and 4 per cent 
other branches. 


The majority of physicians lay stress on skill in 
general nursing care and making the patient com- 
fortable, first; then skill in observing and report- 
ing symptoms; care and following medical orders- 
and last, but not least, good breeding and attrac- 
tive personality. 

What the majority of nurses want are: Reason- 
able hours, adequate income, conservative leader- 
ship and opportunity for growth. 

No efforts were made to solve the difficulties 
which presented themselves, as the Grading Com- 
mittee considers themselves a judicive rather than 
a legislative body. 

My own reaction to the book was general de- 
pression, but as Miss Burgess brings out, nurses 
love nursing. Those that leave the profession 
often come back, and those that do not come back 
often speak of it as of the happiest periods of 
their lives. Although constructive criticism is 
good, I truly believe that no profession, national 


158 


Book Reviews 


organization, committee, or people could stand the 
inspection of a critical person without presenting 
some startling facts. I have been associated with 
college girls and student nurses. They are not 
strikingly different. Nurses are under stricter 
discipline and show more reaction when they are 
free. Less attention is paid to their recreation, 
and they probably need more than any other class 
of people. I know quite a few teachers inti- 
mately and I find that they are often mechanical 
and without definite vision. There will always be 
a few men in the medical profession who do not 
realize the influence of their actions. Yet! No 
better substitute has been found for the present- 
day college, and no one would abolish the teaching 
profession, or loose faith in one of the highest 
profession, a man can choose, because a few 
human beings fall short of the ideal. Neither 
does the nursing profession need an excuse for 
its existence. 

Olive E. Wakefield. 


Studies in the Psychology of Sex: By Havelock 
Ellis. Vol. 7. Philadelphia, F. A. Davis Co. 
1928. pp. 539. 

This supplemental volume to a colossal work is 
a fitting close to a study that is destined to en- 
dure for centuries. The more one reads the 
author, the more one is impressed with the great 
learning of the scholar. His profound knowledge 
of the subject, his skill in handling his material, 
his extensive reading are all imprinted on this 
volume as in the others and are most essential 
information to one interested in this study. 

I. L. Robbins, M. D. 


Clinical Aspects of the Electrocardiogram: By 

Harold E. B. Pardee, M. D. New York, Paul 
B. Hoeber, Inc. 1928. pp. 242. 

This is a second revised edition of a book that 
has definitely established itself as a standard text. 
For the general practitioner it is an excellent ref- 
erence. The information presented is brief, clear 
and concise. Few important changes were made 
in this volume, but the advances made in electro- 
cardiography and the several new machines in use 
and the newer terminology employed are given 
adequate attention. 

I. L. Robbins, M. D. 


Mental Health of the Child: By Douglas Armour 
Thom, M. D. Cambridge, Harvard University 

Press. 1928. pp. 46. 

An essay of sufficient merit to warrant pub- 
lishing in one of the important series of Harvard 
health talks. 

J. H. Musser, M. D. 


Anthelmintics and Their Uses: By R. N. Chopra 

and Asa C. Chandler. Baltimore, The Wil- 
liams & Wilkins Company. 1928. pp. 291. 

This is a comprehensive work on helminthology. 
It not only describes minutely the parasites, but 
analyzes the specific drugs, giving dosage, man- 
ner and administration, toxicology and contrain- 
dications. It is complete, in that it describes 
parasitic infestations of animals and the treat- 
ment, as well as of man. It is, therefore, valuable 
to the veterinarian and to the physician alike. It 
fills a long felt need for a detailed account of 
anthelmintics and their uses. 

H. W. Butler, M. D. 


Mosquito Surveys-. By Malcolm E. MacGregor. 

New York, William Wood & Co. 1928. pp. 

293. 

This book has been prepared for the use of the 
field workers engaged in combatting malaria and 
mosquitoes. It deals first with the anatomy of 
the mosquito in general, and then discusses in de- 
tail the differentiation of the more important 
mosquitoes capable of bearing disease. There is 
a last section on laboratory and field technique, 
which recounts methods of mounting mosquitoes, 
a section on anatomical technique, and on the 
breeding and the rearing of mosquitoes, as well 
as methods of rearing them in captivity. Borne 
ten pages are devoted to field technique. The 
book can be heartily recommended for those en- 
gaged in mosquito campaigns. 

J. H. Musser, M. D. 


PUBLICATIONS RECEIVED. 

Paul B. Hoeber, New York: Rene Theophile 

Hyacinthe Laennec, a memoir, by Gerald B. Webb, 
M. D. 

D. Appleton and Company, New York and Lon- 
don: The Nose, Throat and Ear, by John Barn- 
hill, M. D., F. A. C. S. The Eye, by C. W. Ruther- 
ford, M. D., F. A. C. S. 

J. B. Lippincott Company, Philadelphia and 
London: International Clinics, Volume II, June, 
1928. The Heart in Modern Practice, by William 
Duncan Reid, A. B., M. D. 

Longman’s, Green and Co., Ltd., London and 
New York: Fever, Heat Regulation, Climate and 
the Thyroid Adrenal Apparatus, by W. Cramer, 
Ph. D., D. Sc., M. R. C. S. 

Agricultural Research Institute, Pusa: Memoirs 
of the Department of Agriculture in India, by 
Major R. F. Stirling; Memoirs of the Department 
of Agriculture in India, by J. T. Edwards, D. Sc. 

Calcium Therapy, by John Aulde, M. D., Phila- 
delphia. 


New Orleans Medical 

and 

Surgical Journal 

SEPTEMBER, 1928 No. 3 


Vol. 811 

THE SUGAR-FED CHILD.* 

SEALE HARRIS, M. D. 

Birmingham, Ala. 

Sugar products are the cheapest, most 
abundant and most palatable forms of food. 
They have their uses in that they are 
readily soluble, and by metabolic processes 
in the human body, are converted into heat 
and energy. The excessive use of sugar, 
however, particularly in children, is the 
most serious dietetic error of the present 
day. Statistics shows that the per capita 
consumption of sugar in the United States 
has increased more than 500 per cent in 
the last half century, from 23 pounds per 
capita in 1870 to 120 pounds in 1926. In 
other words, every man, woman and child 
in the United States eats on an average 
one-third pound, about a tea cup full, of 
sugar a day. If this change in our dietary 
habits is a direct, or indirect, cause of dis- 
ease, it is high time that the medical pro- 
fession consider the question seriously ; and 
give the laity the facts, because it is only 
through an enligthened public opinion that 
the perverted appetite of a nation can be 
corrected. 

Concomitant with the unprecedented 
consumption of sugar, eane syrup and corn 
syrup has been an enormous increase in 
the use of white flour, white meal, white 
rice, commercial breakfast foods, white 
potatoes, margarin butter, meats, and 
coffee, which are devoid of vitamins, while 


*Read by invitation before the Mississippi State 
Medical Association, Meridian, Miss., May 9, 1928. 


the family garden, orchard, dairy and 
poultry yard that were formerly a part of 
every farm, and which supplied the protec- 
tive foods required for perfect nutrition, 
are rapidly passing. Sugar saturated, 
vitamin starving America presents a prob- 
lem which may be approached through a 
study of the sugar-fed child, with the idea 
that an ounce of prevention in the infant 
is worth more than the proverbial pound of 
cure in the adult. 

THE SUGAR-FED CHILD. 

To the physician, who knows something 
of the recent advances in the science of 
nutrition, and who studies cause and effect 
in treating his patients, the sugar-fed child 
is one of the saddest sights in the world. 
Such a physician knows that the petted 
and pampered child who indulges in the 
excessive use of sweets will not drink a 
sufficient amount of milk, or eat enough 
eggs, fruits and vegetables, to provide the 
needed fats, proteins, minerals and vita- 
mins for perfect nutrition. He therefore 
knows that the sugar-fed infant often be- 
comes rachitic, and is prone to colitis and 
other infections; and that if he survives 
the diseases of infancy he becomes the 
pale, weak undernourished child; or the 
fat, flabby, indolent and self-indulgent 
adolescent. Likewise, the thinking physi- 
cian knows that his adult dyspeptic, dia- 
betic, or obese patient with heart, kidney, 
or vascular complication, is often the 
grown up sugar-fed child. 

Verily, the child that is born in sugar- 
saturated America is “of few days and full 


160 


Harris — The Sugar-Fed Child 


of trouble.” Soon after his arrival in this 
“vale of tears” he is fed sugar by his fond 
parents, so that his taste becomes per- 
verted during the first days of his exist- 
ence. By the time he is one or two years 
old he is a confirmed sugar habitue, and 
demands that sugar be thick on his oat- 
meal and bread ; and he will not drink milk 
unless it is thoroughly sweetened. He has 
syrup and cakes for breakfast, and sugar- 
saturated desserts for dinner and supper, 
like the rest of the family. He is fed candy 
and soft drinks between meals by kind 
friends of the family, until the life of the 
average child consists of eating and drink- 
ing one sweet after another. Of course 
some parents recognize the harmfulness of 
giving their children too much sweets, but 
with a grocery store and soft drink stand 
on every block, where the boys and girls 
of the community congregate, even if chil- 
dren are properly fed and carefully trained 
at home, they form the sugar habit in their 
early years. 

“The man is but the grown-up child” 
and harmful eating habits formed in child- 
hood become fixed in early manhood; and 
the average adult in America consumes 
about ten times more sugar than is needed 
for nutrition. This excess of a soluble 
carbohydrate ferments in the stomach and 
intestines, forming gas and acid products 
that not only are responsible for many 
functional digestive disturbances; but pa- 
tients with ulcer of the stomach or 
duodenum, chronic gastritis, gall bladder 
infections and other abdominal diseases 
give a history of excessive indulgence in 
sweets too often for it to be a mere 
coincidence. 

WHY IS THE EXCESSIVE USE OF SUGAR HARMFUL? 

Sugar taken on an empty stomach is 
rapidly digested and absorbed and is capa- 
ble of being converted into energy very 
quickly before fermentation can take place. 
Its best use, therefore, is between meals 
for athletes and laborers who need a rapidly 
assimilable carbohydrate. Sugar in that 


way prevents fatigue, increases muscle 
strength and spares tissue metabolism. 

When sugar in any form is taken with 
meals it remains for several hours in the 
stomach, thus favoring fermentation; and 
the greater the amount of sugar ingested 
the more active the fermentation process. 
Cane or beet sugar in solution is a favorite 
pabulum for the fermentative bacteria, 
which produce gas and irritating organic 
acids (lactic and butyric acids) in the 
stomach and intestines. 

Unquestionably many of the digestive 
disturbances both in children and in adults 
result from the fermentation of sugar 
products in the gastro-intestinal tract. 
This is proved clinically by the fact that 
many adult patients who complain of gas- 
tric hyperacidity, flatulency, constipation, 
or diarrhea, give a history of the inges- 
tion of excessive quantities of sweets; and 
in many such patients all that is needed to 
relieve the symptoms is to eliminate sugar 
products from their diet. 

SUGAR IN INFANT FEEDING. 

One of the harmful results from the con- 
sumption of too much sugar products is 
that they satiate and destroy the appetite 
for other more wholesome food. Pedi- 
atricians have learned that the best and 
quickest method to restore appetite in the 
capricious, irritable, undernourished child 
is to eliminate sugar entirely from the diet; 
and they are realizing more and more the 
seriousness of the increasing consumption 
of sugar among children. Some pediatri- 
cians, however, are not entirely blameless 
in creating the craving for sweets in in- 
fants because of their tendency to use more 
cane sugar in modifying milk, particularly 
among poor children whose mothers can- 
not provide them with breast milk. The 
fact that cane sugar is cheap and always 
available, and that milk sugar is expensive 
and more difficult to obtain makes it easy 
for physicians to prescribe it as a milk 
modifier, without thinking of the dangers 
of forming the cane sugar habit in the 
child. 


Harris — The Sugar-Fed Child 


161 


Since milk sugar is less sweet and milk 
modified with it tastes more nearly like 
whole milk, thus accustoming the child to 
use the most nearly perfect article of food 
that can be found for children, is sufficient 
reason to make milk sugar the most desir- 
able soluble carbohydrate for infants ; even 
if there is nothing in the claim that lactose 
ferments less readily than sucrose or sac- 
chrose and that the end products derived 
from the fermentation of milk sugar are 
less harmful than those derived from cane 
sugar fermentative processes. 

There is a growing tendency to use glu- 
cose (com syrup) as a milk modifier in- 
stead of milk sugar. It would seem that 
the same objections which apply to cane 
sugar would also apply to Karo syrup as a 
milk modifier, though glucose is less sweet 
than sucrose. Milk sugar probably con- 
tains vitamin B, while white sugar and corn 
syrup have no vitamin content. 

The use of corn syrup, or glucose derived 
from any other source in threatened or ac- 
tual acidosis may be justifiable for a few 
days at a time, though pure honey, which 
consists largely of levulose and glucose and 
is a natural food, containing vitamin B, 
would seem to be the best source of carbo- 
hydrate for use when needed for combat- 
ting acidosis in children. The possibility 
of manufactured glucose (corn syrup, etc.) 
containing impurities should also be consid- 
ered in using it in infant feeding. There 
can be no doubt but that Dr. Harvey W. 
Wyley had just reasons for his strenuous 
objections to the use of glucose as an adul- 
terant of candy and other foods. 

Condensed milk and other proprietary 
milk products containing a large amount of 
cane sugar will fatten an infant, but clini- 
cal experience has shown that children fed 
on condensed milk are less resistant to in- 
fections than those fed on fresh cow’s milk 
modified with milk sugar or maltose. 

VITAMIN DEFICIENCY PREDISPOSES TO INFECTONS. 

Probably the harmfulness of eating an 
excess of sweets lies most in the fact that 


the sugar-fed child, or the adult sugar 
habitue, lives on a diet that is deficient in 
vitamins that protect against various in- 
fections. He lives largely on white bread, 
white potatoes, white rice, white sugar 
products, lean meats and coifee or tea. The 
child or the man who consumes a great deal 
of sugar rarely eats enough vegetables, 
fruits, or milk products that are rich in 
vitamins and which contain the minerals 
needed for perfect nutrition. In other 
words, he lives on what has been called 
“devitalized” foods, on which laboratory 
animals will starve or develop varied infec- 
tions. 

The observations and experiments of 
McCarrison seem to offer an explanation of 
why the sugar-fed child is more susceptible 
to many infections that one who lives on a 
well balanced diet. It is but just to say, 
however, that McCarrison’s investigations 
seem to prove what Deeks has believed for 
a quarter of a century : that lowered resist- 
ance from an unbalanced diet predisposes 
to many infections. 

McCarrison, a British Army Surgeon, 
stationed in a remote region of the Hima- 
layas, was impressed by the rugged health 
and longevity of the inhabitants whom he 
treated, though they lived under most un- 
sanitary conditions. He said : “During the 
period of my association with these people 
I never saw a case of asthenic dyspepsia, of 
gastric or duodenal ulcer, or appendicitis, 
of mucous colitis, or of cancer, though my 
operating list averaged 400 major opera- 
tions a year.” In his investigations as to 
the cause of this remarkable freedomi from 
abdominal diseases among the primitive 
Himalayans, he was convinced that the use 
of “natural foods — milk, eggs, grains, 
fruits and leafy vegetables” — protected 
them against infection. 

McGARRISON’S EXPERIMENTS. 

McCarrison’s classical experiments seem 
to prove that foods of low vitamin value 
and deficient in certain mineral substances, 
if used over long periods of time, predispose 


162 


Harris — The Sugar-Fed Child 


to infections of the gastro-intestinal tract. 
He also called attention to the effect of an 
improper diet on endocrin function. He 
placed 36 healthy monkeys in two separate 
cages — 12 were fed on natural foods, and 
24 on foods excessive in carbohydrate con- 
tent, deficient in vitamins, and lacking in 
various mineral substances. Of the first 
group all remained healthy and free from 
intestinal disease, while a majority of those 
fed on unbalanced and deficient diets devel- 
oped diarrhoea and actual dysentery. 

McCarrison is of the opinion that vita- 
min B and C serve to protect the gastro- 
intestinal tract from infections; and that 
the deleterious effects of a deficiency of 
these vitamins is enhanced when the food 
is improperly balanced, particularly when 
associated with an excess of carbohydrates. 
Again quoting from McCarrison: “Impair- 
ment of the protective resources of the 
gastro-intestinal mucosa against infecting 
agents may be due to hemorrhagic infiltra- 
tion, to atrophy of the lymphoid cells, and 
to imperfect production of gastro-intestinal 
juices. This impairment not only results 
in infections of the mucous membrane it- 
self, but also permits of the passage into 
the blood stream of micro-organisms from 
the bowels.” 

McCarrison showed, by illustrations of 
sections of various parts of the intestines, 
that all these changes occur in animals 
which have been fed on diets poor in vita- 
mins and with an excess of carbohydrates. 
He claims that “diarrhea, dysentery, dys- 
pepsia and gastric dilatation, gastric and 
duodenal ulcer, colitis, and failure of colo- 
nic function can be produced experimen- 
tally by means of feeding animals on faulty 
food.” He does not claim that the faulty 
diet is the only cause of these gastro-intes- 
tinal conditions, but insists that pathogenic 
organisms are contributing factors. As 
proof that a faulty diet lowers resistance 
to infections, McCarrison fed healthy mon- 
keys on entameba histolytica and failed to 
infect any of them ; while those fed on a 


deficient diet became readily infected when 
given the entameba histolytica organisms. 

The pure carbohydrate diet that McCar- 
rison fed to monkeys which resulted in vari- 
ous abdominal lesions due to infections by 
pathogenic microorganisms is only a little 
less restricted than the white bread, cereal, 
potato, sugar diet that is eaten by a large 
proportion of the people of the United 
States. It is a significant fact that more 
than 25 per cent of patients admitted to 
American hospitals suffer from medical 
and surgical diseases of the abdomen ; and 
no doubt the excessive use of sugar is a 
factor of importance in predisposing to 
colitis, appendicitis, ulcers of the stomach 
and duodenum, and gall bladder, liver and 
pancreatic infections. 

THE RELATION OF SUGAR TO MOUTH INFCTIONS. 

The child with a “sweet tooth” grows up 
to become the toothless middle aged man or 
woman. No one who knows anything of 
the bacteriology of dental caries can doubt 
that the acid fermentation between the teeth 
and at the edges of the gums in the mouth 
of those who eat and drink sugar products 
will in time cause decayed teeth. No doubt 
pyorrhoea, Vincent’s angina and other oral 
diseases are likewise more frequent in the 
sugar habitue, not only because of the local 
irritating effects fromi carbohydrate fer- 
mentation ; but because the sugar saturated 
child or man lives on a diet which is defi- 
cient in the antiscorbutic vitamin, the pre- 
disposing cause of mouth infections. 

Probably one of the reasons why the 
young people of this day have such poor 
teeth and have so many dental deformities 
is that the sugar-fed child’s diet is not only 
deficient in vitamin D, but also in calcium 
and phosphorus, which are necessary for 
the ossification of the teeth and bones. 
McCollum in his experiments on animals 
produced all kinds of deformities of the 
teeth and bones by depriving them of vita- 
min D and calcium and phosphorus. In 
other words a diet such as the average 
sugar-fed child lives upon will produce 
rickets with various dental abnormalities. 


Harris — The Sugar-Fed Child 


163 


McCollum has also demonstrated by feed- 
ing laboratory animals on deficient diets 
that the quality of the teeth of the offspring 
depends upon the mother’s being properly 
nourished. The infant of the sugar-satu- 
rated human mother is therefore likely to 
be born with defective tooth buds, and the 
teeth which are developed from them are 
further impaired by a deficient diet in the 
growing child. We shall have to change the 
eating habits of mothers as well as of their 
children if we would save the teeth of the 
coming generation. 

DEEKS’ INDICTMENT OF SUGAR. 

Deeks, formerly Chief Physician to 
Ancan Hospital on the Canal Zone, and who 
has been at the head of the Medical De- 
partment of the United Fruit Company for 
many years, has written many articles call- 
ing attention to the harmfulness of the ex- 
cessive use of sugar products. In a recent 
monograph entitled, “Diet and Disease,” 
Deeks gives a very plausible explan- 
ation of the deleterious effects of a high 
carbohydrate diet, with particular refer- 
ence to the end results from the fermenta- 
tion of cane sugar in the stomach and intes- 
tines. The following excerpt from his arti- 
cle is worthy of consideration by thinking 
physicians : 

“When fermentation takes place through 
the action of bacteria, not only gasses are 
liberated, but other products are formed, 
some of which are toxic in character. The 
nature of the fermentative process can be 
very well illustrated by a consideration of 
the action of yeast upon grape-sugar. As 
the yeast cells grow and multiply, the sugar 
is converted into alcohol and carbon diox- 
ide. Other organisms by means of their 
ferments produce lactic, butyric acids, 
etc., from' sugars.” 

“As products of fermentation in the di- 
gestive tract, there is not only the forma- 
tion of gas, but other products as well, 
which are toxic and irritating. The gasses 
formed are eliminated by eructations from 
the stomach, or through the rectum ; or by 


the lungs if obsorbed into the circulation. 
The other products, however, resulting 
from the action of bacteria are soluble and 
absorbed into the circulation, whence they 
must be excreted. When these are very 
irritating or toxic, they produce lesions in 
tissues, not only where they are locally 
formed in the alimentary tract, but also 
while circulating in the blood and while 
they are being excreted by the kidneys, 
skin and lungs.” 

“Some toxic products are selective for 
tissues after the manner of the selectivity 
of toxic products of pathogenic bacteria. 
Certain authorities believe that some of the 
fermentative products are selective for 
fibrous connective and other specialized tis- 
sues, which they irritate. Irritation of tis- 
sue is frequently associated with pain and 
usually means lowered resistance to the in- 
vasion of bacteria, some of which are more 
pathogenic than others. As fibrous con- 
nective tissue is the supporting and bind- 
ing element of the cells and is present in 
all tissues, any toxin affecting it is likely 
to produce symptoms which may be re- 
ferred to any part of the body. When toxic 
products are absorbed into the circulation, 
their concentration and effects will be local- 
ized where there is the greatest physiologi- 
cal determination of blood or lowered re- 
sistance from any cause. In sufferers from 
rheumatism, the limb doing the most physi- 
ological work is usually most affected; and 
because of lowered resistance due to ex- 
posure, draft, or injury, symptoms are 
likely to follow in the location exposed. 
From similar causative factors morbid 
lesions vary in different individuals, influ- 
enced by age and idiosyncrasy. A child is 
more likely to suffer from bronchitis, irri- 
table bladder, and endocarditis; a grown 
person from rheumatic pains, lumbago, ar- 
thritis, neuritis, pleurisy, headaches, etc. 
Personal idiosyncrasy, chemotaxis, and 
selective bacterial affinities generally deter- 
mine the location of morbid processes. In- 
fluenza produces in different individuals 
symptoms referable to the nervous, diges- 


164 


Harris — The Sugar-Fed Child 


tive, respiratory or excretory systems re- 
spectively; so will the products of fermen- 
tation.” 

"Of the different forms of carbohy- 
drates, saccharose is considered the most 
fermentable. It undergoes no change in 
the stomach, as there is no ferment to han- 
dle it before it reaches the intestine, where 
it is acted upon by invertase, converting it 
into dextrose and levulose. When saccha- 
rose is taken with a full meal and the stom- 
ach is not emptied for several hours, owing 
to its proneness to be acted upon by fer- 
mentative bacteria, it becomes converted 
into irritating organic acids or toxic prod- 
ucts, which are diffusible and absorbable. 
Because of their irritating properties, they 
stimulate locally over-secretion of the gas- 
tric glands, and hyperacidity results. If 
this action is continued over long periods 
of time, the gastric glands become exhaust- 
ed from over-stimulation and anacidity re- 
sults. The stomach functions are changed 
from that of a digestive organ to that of a 
fermentative food-containing sac. Saccha- 
rose is undoubtedly a very useful, quickly 
available, muscle food, if taken on an empty 
stomach or from three to four hours after 
a meal. If, however, it is taken with a 
bulkly meal in artificially sweetened foods 
or drinks, fermentative bacteria may at- 
tack it and other carbohydrate foodstuffs 
before they can leave the stomach, and the 
effects are manifested in a variety of 
ways.” 

“It may be concluded, therefore, that any 
tissue or group of tissues in the body can 
be affected as a result of excess carbohy- 
drate consumption of (1) its proneness to 
fermentation with the development of 
gaseous and toxic products, and (2) the 
deficiency of inorganic mineral salts and 
vitamins.’” 

“Among the symptoms, symptom-com- 
plexes, and organic diseases which neces- 
sitate careful investigation in regard to the 
quantity and nature of the carbohydrate 
content ingested may be mentioned: Peri- 


odical headaches including migraine, sto- 
matitis, chronic pharyngitis, dental decay, 
spongy bleeding gums, focal infections, 
flatulent and acid dyspensia, gastric ulcer, 
appendicitis, constipation, diarrhea, skin 
manifestations, such a furunculosis, eczema, 
acne, psoriasis, and alopecia of certain 
types ; rheumatic phenomena, including 
neuritis, lumbago, torticollis, dysmenor- 
rhea, arthritis, endocarditis, etc., other 
conditions of undetermined etiology may 
be mentioned, such as the development of 
gall, kidney and bladder calculi; arterios- 
clerosis, chronic interestitial nephritis, 
retino-choroiditis, ulcerative keratitis, etc.” 

“In children, the symptoms of those 
using excessive amounts of sweet and 
starchy food are characteristic. Fickle ap- 
petites, irritability, restlessness, lustreless 
hair, eneuresis, recurring bronchitis, hy- 
pertrophic tonsillitis, eczema, endocarditis, 
etc.” 

“It is not claimed that the excessive 
use of carbohydrates and the absorption 
of the fermentative products are the only 
factors involved in the above mentioned 
conditions. When people consume an ex- 
cessive quantity of acid ash producing 
foods, like meats and the cereal deriva- 
tives, which are generally devoid of vita- 
mins and deficient in inorganic salts, they 
are taking insufficient amounts of the 
foods belonging to the group of green 
vegetables and fresh fruits, which are the 
main supply of vitamins and alkaline in- 
organic salts. The inadequacy of vitamins, 
as well as an improper relationship or 
quantity of inorganic salts, undoubtedly 
plays important roles in the production of 
morbid conditions, either in predisposing 
to acute infections or organic tissue de- 
generations. However, the consumption 
of excessive amounts of the fermentable 
sweet and starchy foods in an important 
dietetic error that has not been sufficiently 
stressed. Though dietetic errors may be 
transgressed without impunity over cer- 
tain limited periods of time, sooner or 


Haeris — The Sugar-Fed Child 


165 


later morbid processes insiduously ensue. 
Eecurring headaches, premature tooth de- 
cay and digestive disturbances of all kinds 
should be warnings to an individual that 
the food he has been in the habit of in- 
gesting is not being properly metabolized, 
and steps should be, taken to balance his 
diet, restricting it to those quantities and 
combinations of foods or classes of foods 
which he can handle with impunity.” 

EDUCATION THE REMEDY. 

Thomas Jefferson said : “The present 

generation is already lost. Let us educate 
the youth of the country,” so he founded 
the University of Virginia, and he consid- 
ered his contribution to education as his 
life’s greatest work. The “father of de- 
mocracy” was almost right; because it is 
difficult for adults who have been eating 
excessively of sugar products all their 
lives to realize that overweight which will 
surely shorten life, comes largely from 
the excess of sugar that is converted into 
fat. The adult, however, can ' be taught 
that sugar in any quantity need not be 
given to a child under one year of age; 
and that it should be eaten sparingly by 
children of all ages, because many of the 
ills of childhood have for their direct, or 
predisposing cause, the unnecessary sugar 
habit. 

Progress is being made in teaching chil- 
dren the simple principles of nutrition both 
by text book instruction and by various 
nutritional clinics and studies in the public 
schools. For instance, it was found that 
20 per cent of the school children of Massa- 
chusetts are undernourished. No doubt 
the children in other states fare no better, 
and often it is the child of wealthy parents 
who suffers most from faulty eating habits. 

Educators are awakening to the fact 
that the undernourished child, in whom 
the excessive use of sugar is usually a con- 
tributing factor, accomplishes less than his 
well nourished deskmate, and that, as the 
child becomes better nourished, his class 
standing improves. It would be interest- 


ing to compare the class standing of the 
sugar saturated children of a school with 
that of those who live on a well balanced 
diet. 

The sugar-fed child is really a public 
health problem, as much so as the tuber- 
culous infant, and health officers and 
welfare nurses should educate the public 
regarding the harmfulness of the exces- 
sive use of sweets, just as they have done 
in their campaigns against the communi- 
cable diseases of childhood. The parent- 
teachers’ associations should see to it that 
school children are taught proper eating 
habits; and that they are not tempted 
every hour in the day to eat candy or drink 
soda water and other sweet drinks. The 
so-called cola drinks are particularly 
harmful, not only because they contain too 
much sugar, but their popularity depends 
upon the habit forming drug, caffeine, 
which it contains, that is particularly de- 
leterious to the health of children. The 
health officer of one of the rural counties 
of Alabama informed me recently that 60 
per cent of the children in one of the 
schools admitted the more or less regular 
use of the most popular of the cola drinks. 

Likewise, the medical profession should 
study the harmful effects of the excessive 
consumption of sugar by person of all ages 
and physicians everywhere should do their 
part in teaching the public the facts that 
they know regarding diet and nutrition. 

The most important problem in this 
land of sweets is to teach all people of all 
ages the dictum of McCollum’s perfect 
nutritional day, i. e., that each normal 
person from childhood to old age should 
drink from a pint to a quart of milk, and 
eat one raw fruit, one raw vegetable and 
two cooked leafy green vegetables each 
day. After that he may eat a reasonable 
amount of meat once a day, one or two 
slices of bread, preferably made of whole 
wheat flour or country-ground corn meal, 
with butter at each meal, and then a light 
dessert — ice cream, sherbet, or fruit at 


166 


Harris — The Sugar-Fed Child 


one meal. When the known facts regard- 
ing- nutrition are learned and practiced by 
all the people, in a few generations we 
shall have a race of super men and women 
in fortune-favored America. 

DISCUSSION. 

Dr. W. A. Dearman (Gulfport) : I was un- 

fortunate in getting in too late to hear the cap- 
tion of Dr. Harris’ paper, but his papers are 
always pregnant with ideas that are fundamental 
and worth while. 

The health departments are directing attention 
to the teeth of the sugar-fed child who is inducted 
into the habit by its parents. I am afraid we 
do not take into consideration the value of the 
fundamentals that have been laid before us by 
dentists who understand this condition, nor do we 
put them into practical relationship with de- 
ficiency diseases. 

In days past and gone, with reference to 
typhoid, the patient was instructed to live on 
chicken broth and nothing else. He came out a 
human wreck, emaciated, pale, and weak, and his 
chances for recovery very much embarrassed. 
We find now that since we have acquired ideas 
that have been worked out on a scientific basis, 
we can bring the patient through the entire 
course of typhoid from the incipiency to the end 
of convalescence with practically the same weight 
that he had at the time he went to bed. That is 
a capital achievement in the treatment of this 
treacherous and most formidable condition that 
once was a scourge to our people of the United 
iStates. I have always been afraid to advise as 
to diet. I am afraid we find too many of our 
physicians who know very little of diet and the 
food values. I used a diet, long, long ago, figured 
out on the basis that there was starch in pota- 
toes — that they contained 100 per cent starch — 
that it was in rice, and in turnip greens. That 
isn’t true. Diabetics are big sugar eaters, starch 
eaters, and their lives are cut short. Too many 
doctors find patients who are too stout, and some 
under-nourished. Some of my patients were in- 
sulted when I said they were under-nourished. I 
practiced medicine before I had any scales in my 
office. We paid no attention to over and under 
weight, but now it is the most important thing, 
and it is a very easy matter for any doctor in 
a practical way to treat a profound diabetic in 
a small town or rural district by paying close 
attention at least to some of the fundamental 
principles of food values. 

Dr. Seale Harris (closing) : I appreciate Dr. 

Dearman’s discussion. He always says something 
that you can carry home with you and put to 
profit. He is one of the most practical men I 
know of. He spoke of the question of bad teeth, 
particularly in children. The deficiency of teeth 


is due very largely to a deficiency diet — bad teeth 
in infected mouths and gums. McCollum by diet- 
ing rats was able to produce almost any defor- 
mities in teeth, and of course various other 
deformities, by simply giving them a diet with- 
out vitamin D, contained in milk and eggs. That 
diet is also deficient in calcium and phosphorous. 
If you will study the diet of the average child — 
the infant — you will see »that when the child is 
given a little sweet he won’t drink enough milk — 
he won’t eat vegtables, and many of them will 
not take eggs. Therefore, their diet is deficient 
in vitamin D, in calcium and phosphate, and 
it is almost as certain as the sun rises, that 
the child that is fed on a diet deficient in vitamin 
D, unless given a good deal of sunlight is going 
to have bad teeth, and he is going to have the 
rickets — he is going to have other troubles. 
McCullum says that 95 per cent have rickets before 
they are a year old. Don’t misunderstand me — I 
don’t mean to say that sugar is poisonous or is 
harmful in itself, but, on the contrary, it is an 
excellent form of good. Its principal use as a 
food lies not in eating between meals when the 
stomach is empty, when it is probably absorbed 
and immediately utilized, for instance, after a 
long, hard day, a few chocolates or a glass of soda 
water is helpful. It tides one over fatigue and it 
is really needed. 

When much sugar is taken into the stomach 
with meals it stays there for hours and sometimes 
longer. It ferments and is productive of organic 
acids irritating to the stomach. 

Doctors should be teachers. That is a 
thing that, personally, I am doing nine-tenths 
of my time, and I consider following the diagnosis 
the most important thing is to teach the patient 
how to live. Teach the patient the harmfulness of 
the excessive use of sweets.. Nutrition is being 
taken up now by the public health authorities in a 
practical way, and it is doing a great deal of good. 


PREVENTION AND MODIFICATION OF MEASLES BY 
MEASLES AN-nOIPLOCOCCUS GOAT SERUM. — Louis J. 
Halpern, Chicago, reports that fifty patients who gave a 
definite history of never having had measles were given 
measles antidiplococcus goat serum as a protection against 
measles. Five patients in this series died from three to 
ten days after receiving serum. Their deaths, however, 
were due to th* illnesses for which they were originally 
admitted to the hospital; they did not develop measles nor 
did any serum sickness occur before death. Of the re- 
maining forty-five patients in this series, twenty-eight 
patients, or 63 per cent, were successfully protected. 
While seventeen developed the disease, the majority of the 
latter experienced it in attenuated form. In spite of the 
fact that eight patients received serum after the fourth 
day of exposure, three of these, or 38 per cent, were pro- 
tected. It is especially noteworthy that not a single com- 
plication occurred in any of the patients treated with serum 
who developed measles, nor was there any instance of a 
serum reaction in the entire series. He concludes that 
measles antidiplococcus serum apparently effected immuni- 
zation against measles in a large percentage of cases. — 
J. A. M. A., April 17, 1928. 


Unsworth — Malaria Therapy in Paresis 


167 


MALARIA THERAPY IN PARESIS.* 
H. R. UNSWORTH, M. D. 

New Orleans. 

INTRODUCTION. 

In 'February, 1927, this patient was in- 
oculated intravenously with 5 cc. of ter- 
tian malaria. In June of the same year he 
reported back to work, since which time he 
has been re-engaged in his former occupa- 
tion. He is married, has a wife and five 
children and, as far as we can see, is per- 
fectly well. 

Dr. Johns, I believe, is quite familiar 
with the patient with his acute outbreak 
and would possibly have something to say 
on the subject. As far as we know, psy- 
chically and neurologically, the man is as 
he was before his infection or acute clini- 
cal symptomatology. 

We might have presented many cases 
demonstrating the benefit derived from 
malaria treatment in paresis, but chose 
this patient because his treatment ante- 
dates the others, which has the advantage 
of a longer period of observation of re- 
sults. We have had the some success in 
the other cases. 

Anticipating any therapy in diseases of 
the cerebro-spinal axis, it is most import- 
ant to recall its anatomical structures, the 
units (of which you are familiar) being 
exquisitely sensitive to any trauma, be it 
physical, chemical, or psychic, and to dis- 
regard this bit of caution will invariably 
discredit any therapy undertaken, some- 
times with unexpected fatalities. 

There is little doubt that paresis, without 
going into any statistics, has increased 
within the past fifteen years. The distress- 
ing realization that its onset has become 
more rapid and that the average paretic is 
of an earlier age, suggests that the viru- 
lence of the organism is not alone to blame, 
or that there is any particular neuro- 
trophic spirochete, but instead, the ex- 

*Read before the Orleans Parish Medical 
Society, March 12, 1928. 


planation lies in my mind in too vigorous 
an attempt to combat the disease with mod- 
ern intravenous therapies, disregarding 
superimposing a chemical enarteritis upon 
an already specific one. The attention of 
some authorities, such as White and Free- 
man at St. Elizabeth’s Hospital in Wash- 
ington, has been attracted to this possi- 
bility and will no doubt be more vigorously 
stated as their observations and research 
progress. Is it not reasonable to suppose, 
when one stops to consider the pathology 
in paresis, that such is a distinct factor 
and not an ultra scientific thought? 

Paresis, briefly, is a meningo-encepha- 
litis. The cortex of the cerebrum is 
composed of nerve cells, a network of 
nerve fibers and processes, neurologic 
tissues with a superimposed vascular 
mem'brane^ — the pia mater. In paresis, 
the outstanding pathological feature is the 
active formation of new vessels in the 
cortex with dilated capillaries and widened 
adventitial lymph spaces. These lymph 
spaces are filled with lymphocytic and 
plasma cells. Throughout the brain there 
is focal, diffuse and tract degeneration. 
The very nature of the pathology suggests 
the hopelessness of 'improvement with 
chemical therapy : it is merely another 
source of irritation and encourages pro- 
liferation changes. 

It is with this impression that I feel 
we are justified in attempting any reason- 
able measures which appear to offer, if not 
a cure, a more pronounced improvement — 
that is, longer remissions. Malarial in- 
oculation, however, is not to be recklessly 
or unintelligently used. Giving one dis- 
ease to combat another is a serious matter, 
and on all occasions to be used only in 
selected cases with due consideration of 
the physical status of the individual. There 
are to my mind, certain definite contrain- 
dications, viz : cardio-vascular involve- 

ments, syphilitic hepatitis, pronounced 
renal involvements and general physical 
deterioration. And, is not reasonable to 
assume that too vigorous arsenical therapy 


168 


Unsworth — Malaria Therapy in Paresis 


hastens the pathologic process and there- 
fore may be classed as a contra-indicative? 

As early as 1887 the idea that the bene- 
ficial results from the induction of fever 
in certain cases appeared to give good 
results, was expressed by Wagner von 
Jauregge, chief of the Psychiatric Clinic at 
Vienna, in an article on “Influence of 
Febrile Diseases in Psychoses.” He began 
by using Koch’s old tuberculin in the 
treatment of general paresis, giving his 
patients increasing doses, subcutaneously, 
three times a week. He allowed eight to 
twelve elevations of temperature. This 
was followed by mercury. In comparing 
the treated paretics with an equal number 
of untreated ones, he found that the lives 
of those treated were longer and the re- 
missions more pronounced and lasting. In 
cases of general paresis where tuberculin 
was contraindicated, Bedreska used ty- 
phoid vaccine. This he gave intraven- 
ously every other day and received very 
satisfactory results. He also used staphy- 
lococcus and streptococcus vaccines, but 
abandoned these because the remissions 
were of short duration. Donath of Vienna 
and Fisher of Prague treated cases by in- 
tramuscular injections of sodium nuclein- 
ate, but because of pain and suppuration, 
this had to be abandoned. Wagner von 
Jauregge concluded that his best results 
were obtained in cases where he used 
intercurrent febrile diseases. So, in 1917, 
he inoculated nine paretics with malaria 
(tertian). His original technique, as re- 
ported in the Journal of Nervous and 
Mental Diseases, Vol. 55, No. 5, May, 
1922, was as follows : He injected from 

one to four c.c.’s of malarial blood ob- 
tained during an attack of fever and 
inoculated the patient subcutaneously. 
Occasionally he would rub malarial in- 
fected blood on scarifications in the upper 
arm as in small pox vaccinations. He 
sometimes used the specimens of blood 
between the paroxysms of fever and chills. 
Usually the malaria developed from six to 
thirty-six days after the inoculation. He 
allowed from eight to nine, sometimes as 


many as twelve, elevations of temperature 
when the patient could stand it. Wagner 
Von Jauregge concluded that remissions 
occurred in 50 per cent of his cases, the 
patients actually returning to their former 
occupations. He observed, especially, that 
speech defects and epileptiform attacks, 
were benefited following malarial therapy. 
He also concluded that the sera of these 
patients were only negligibly influenced. 
Therefore, he regarded his serological 
findings as of diagnostic import but not of 
any prognostic significance. He also con- 
cluded that the earlier a paretic was in- 
oculated the more pronounced the im- 
provement. 

O’Leary of Rochester, Minn., in an ar- 
ticle in the A. M. A. Journal reported the 
results in one hundred cases treated with 
malaria between June, 1924, and February, 
1926. He gave particular attention to the 
resistant parenchymatous forms of neuro- 
syphilis, including incapacitating gastric 
crises, lightning pains in the legs and 
optic atrophy in tabes dorsalis. Fifty- 
seven of these 100 cases were cases of 
general paresis, 49 per cent of which were 
Still in remission as measured by the 
economical status of the patient. Thirteen 
patients, presenting the syndrome of pare- 
sis, sine paresis or asymptomatic general 
paresis showed material improvemet ; in 
four the blood and spinal fluid were 
normal. The evidence supported the 
assertion that in the serologically negative 
cases of tabes with persistent lightning 
pains or gastric crises, malarial inoculation 
had been beneficial. In cases of optic 
therapy, benefit resulted. Four of nine 
treated cases showed the loss of vision had 
app-arently been arrested. He reported a 
mortality of 5 per cent in those cases in 
which malaria was considered as a factor. 
Clinical results were more pronounced 
when the fever treatment was instituted 
early in the course of the disease. Striking 
results were, however, seen in cases where 
clinical signs of general paresis were 
present two, three or four years before 
inoculation. It is to be borne in mind that 


Unsworth — Malaria Therapy in Paresis 


169 


the serological changes are not always 
paralleled by clinical improvement. This 
was confirmed by observation of cases in 
complete remission, some of which mani- 
fested no serological changes. On the 
other hand, cases with complete change in 
all the factors in the spinal fluid and blood 
might terminate in sudden death. O’Leary 
concluded that malarial therapy offered the 
most valuable method of treatment in 
paresis, and that his best results were 
obtained with anti-syphilitic treatment fol- 
lowing a course of malaria. 

Watson W. Aldridge, Jr., of St. Eliza- 
beth’s Hospital, Washington, D. C., was 
the first to undertake, in this country, the 
malarial treatment in general paresis. He 
inoculated the first patients in December, 
1922. In a general survey of these cases, 
some of more than five years’ standing, he 
found that remissions had occurred in 61 
per cent of the cases, complete remissions 
running about 40 per cent or a little less. 
From recent correspondence with Dr. 
Walter Freeman of St. Elizabeth’s Hospi- 
tal, I quote the following: “In regard to 

the malarial proposition we are still as 
enthusiastic as ever although we do not 
say it is the only treatment. We do be- 
lieve, however, that some form of fever 
treatment is superior to all other forms. 
We have recently been surveying our five 
year cases and find that the percentages 
found after three years have remained 
practically constant. In other words, that 
there have been no recrudesences in the 
satisfactorily treated cases. Some 30 per 
cent are considerably improved, many of 
them holding jobs on the outside, about 30 
per cent or so are rested but showing 
psychic scars from which there is little ex- 
pectation of recovery, a scattering deteri- 
orating still, and a somewhat larger per- 
centage dead. Of course, in comparison 
of the usual run of life in paretics, the 
statistics are outstanding, for scarcely one 
in a hundred ordinary paretics would be 
alive at the present time, five years after 
remission. 


“I am still impressed with the effect 
upon the anatomical picture, having just 
recently had occasion to examine a brain 
from a paretic treated who died fourteen 
months later. Paresis is not recognizable 
in the slides from the brain. I am sending 
you a reprint of my article on the anato- 
mical changes and refer you to last year’s 
Medical Journal and Record, Ferrarros’ 
contribution detailing the three years’ re- 
sults from a clinical and serological stand- 
point. The latter are exceptionally impor- 
tant in administrating the long time 
necessary before evaluating the results. 

“At the beginning of our sixth year, we 
have inoculated recently another batch of 
65 paretics which the malaria is working 
well. I hope you can introduce this form 
of treatment successfully for as I see it it 
offers far more hope than any other form 
devised. 

“We are beginning to think here that 
arsenical treatment is an important predis- 
posing cause in the development of paresis 
in a syphilitic, but we have not yet mar- 
shalled our figures.” 

In the few cases I treated with Dr. C. V. 
Unsworth in the Louisiana Retreat, New 
Orleans, this past year, the results ob- 
tained appear almost miraculous. It is of 
particular interest that these cases had 
received no previous specific therapy and 
that they were of the ideal type in that 
they were recognized early, and of vigor- 
ous physical make-up. Briefly, these cases 
presented typical serological findings with 
delapidation in the psychic field. Neuro- 
logically they were organically negative 
except for pupillary abnormalities with 
slight exaggerations of knee jerks. They 
were brought to us with the personality 
changes — ^the outstanding feature of which 
was grandiosity. One case, our only 
fatality, had previously received intensive 
intravenous therapies with definite so- 
matic disease. Contrary to general impres- 
sion, our best results have been obtained 
by subcutaneous inoculations; our failures 


170 


U NS WORTH — Malaria Therapy in Paresis 


were 100 per cent intravenously. In our 
series, symptomatic malaria appeared from 
ten to fourteen days after inoculation. The 
quantity of malarial blood injected varied 
from 3-10 cc. In three cases it was free 
from syphilitic infection — vi^hich we be- 
lieve is more desirable; the pure malaria 
plasmodia seeming to be of a more viru- 
lent type. In all instances, these patients 
were allowed to defeat the malaria, being 
alert for any sign of symptom which 
might call for immediate malarial therapy. 
The outstanding features of which we are 
particularly apprehensive being acute 
jaundice or an extreme hyperpyrexia with 
convulsions. A hypernutrition diet with 
elimination were considered essential in 
sustaining the patients during the acute 
illness. 

SUMMARY. 

Malaria therapy in paresis is particu- 
larly indicated in the early untreated cases 
and in those of vigorous physical make-up. 
The earlier a paretic is inoculated, the 
more favorable the prognosis. Best results 
are in those patients who are allowed to 
defeat their ovm infection. In my hands, 
subcutaneous inoculation has been the 
method of choice and has resulted in a 
greater number of '“takes.” Somatic dis- 
ease, general physical debility are definite 
contraindications. The most pronounced 
improvements have been in the psychic 
sphere. In our unsuccessful inoculations 
we have concluded either our technique 
was at fault, the organism of an atten- 
uated character — ^that is, weakened — or 
the patient possessed a natural immunity. 

DISCUSSION. 

Dr. C. S. Holbrook (New Orleans) : The pic- 

ture presented by paresis has been so discourag- 
ing that anything that points to improvement is 
well worth while. These cases, up to the pres- 
en'' time, have practically always died within 
three years after the infection, or rather after 
the disease has become w'ell recognized. In the 
hospital one does not find very many general 
paretics; dementia praecox constitutes about fifty 
per cent of the hospital population with a com- 
paratively small percentage of paretics, not that 
the disease is rare, but because death occurs 
v/ithin three years — at least that has been the 


experience until quite recently. Now we feel 
more hopeful about it and believe that inocula- 
tion with malaria will give results that cannot 
be equalled by any other treatment. Just why 
malaria should be of greater value than other 
forms of hyperpyrexia is not understood. There 
apparently is some metabolism deficiency in the 
paretic. It has been noticed for years that the 
patients who develop paresis, about four to five 
per cent of those who contract syphilis, have little 
systemic effect and no skin reaction. It has b»en 
held that the metabolic resources of the body 
were at fault. Bringing about high temperature 
by vaccine or milk, has not given as good re- 
sultes as the malaria treatment and it is thought 
that the introduction of this disease in some way 
increases or overcomes the existing deficiency. It 
is rather interesting to note the report on several 
of these cases treated by this method. 

Report No. 1. Markowitz in 1925 reported a 
case. The patient developed a gumma of the 
skin of the forehead just two months after being 
cured with malaria, that is, “cure” as the word 
is used. 

Report No. 2. F. 0. Schulze, in another arti- 
cle, reported tertiary syphilis of the skin in three 
cases of paresis subsequent to treatment with ma- 
laria. 

Report No. 3. Wagner von Jauregg also 
showed in a typical paretic one year after treat- 
ment and restoration the patient developed apha- 
sia, agraphia and Jacksonian attacks, but no 
psychic disturbance. Treatment with mercury 
and salvarsan cleared up the slighter symptoms. 

They attempt to show that the specific reac- 
tion was taken care of by changing the resistance 
of the body through the inoculation of this dis- 
ease, malaria. It may be true. The best results 
are achieved where malaria is brought about with 
some other treatment; as Dr. Unsworth has indi- 
cated, salvarsan, mercury, bismuth salicylate and 
some of these drugs. 

My experience with malaria has not been very 
extensive; the opportunity to handle these cases 
in private practice does not occur as often as 
one might hope. I have twelve cases that have 
gone back to work; I have two others that are 
demented. On the whole, the results are en- 
couraging. The remissions are brought about in 
25 to 60 per cent, depending on the criteria that 
the various men hold as cure or remission. This 
malaria treatment, of course, carries -with it a 
rather dangerous mortality or morbidity. One 
patient gave me a great deal of worry. He devel- 
oped fever 107° and every red cell contained 
malaria plasmodia. I was terrifically upset about 
it. The patient did very well under anti-malarial 


U NS WORTH — McUaria Therapy in Paresis 


171 


treatment. I think some of these cases do not 
respond to malarial treatment. Some will not 
contract the disease. Recently I had a patient 
who was given malaria and after a short time, 
four to five days, he spontaneously recovered 
from his malaria, so in that case this form of 
treatment had to be discarded. He might have 
been treated with milk or Koch’s vaccine and 
possibly gotten good results. 

There is one warning that might well be 
sounded, viz: that malarial treatment should not 
be given in any cases of syphilis of the nervous 
system except the patient has paresis or tabes. 
There has been a great deal of publicity about 
this treatment and it has been suggested that all 
types of cerebro-spinal lues should be treated 
with malaria. It was only recently that I had 
a comparatively simple case of cerebrospinal sy- 
philis sent from Texas with the request that 
this patient be given malarial treatment. This 
would have been dangerous and unwarranted. 
Results can be brought about in these cases with 
simple anti-luetic measures. Only the parenchy- 
matous syphilis (paresis and tabes) should be 
treated by inducing malaria. 

Up to the present this treatent, as outlined by 
Dr. Unsworth, has given most satisfactory results. 
It will require observation over a long period of 
years before the benefits from the malarial treat- 
ment of paresis can be evaluated. 

Dr. F. M. Johns (New Orleans) : Before the 

malarial treatment of paresis was instituted, I do 
not believe that there was a more hopeless picture 
with regard to the treatment of syphilitic patients 
as seen by the laboratory man than that shown 
by the average patient developing paresis. Be- 
ginning at the diagnosis made by the positive 
spinal fiuid findings, practically every case that 
I have seen over any period of time has shown 
a gradual increase in the positive findings in the 
spinal fluid, together with an apparent progres- 
sion of the mental deterioration of the patient. 
Occasionally an early case would yield to very 
intensive arsenical and mercurial treatment and 
I have seen a very few cases only with central 
nervous involvement in which the laboratory find- 
ings in the spinal fluid were negative. We have 
just seen a case presented by Dr. Unsworth who 
has been apparently completely restored to nor- 
mal. I had the pleasure of examining this patient 
at the time the malaria treatment was instituted 
and I can assure you that his recovery from a 
condition of actual mania to the perfectly normal, 
co-ordinating, intelligent human being of tonight 
is little short of marvelous. I have seen several 
other instances in which the results were just as 
striking and in several of whom the spinal fluid 
findings are gradually returning to normal. 


In Philadelphia last spring I had the pleasure 
of seeing a number of patients treated by Dr. 
Frank Schamberg, Director of the Dermatological 
Research Laboratory, during which time quite a 
number of cases of apparently cured paresis were 
presented. Dr. Schamberg remarked that it was 
the consensus of opinion among many neurolo- 
gists who had been following these cases that 
nothing in the annals of treatment of paresis so 
far had produced anything like the favorable 
results obtained by the malaria form of treatment. 

While the treatment itself is rather severe, I 
believe that in well selected cases of otherwise 
physically healthy individuals this form of treat- 
ment is undoubtedly the method of choice at pres- 
ent and certainly offers the only hope of a clini- 
cal cure. 

Dr. C. V. Unsworth (New Orleans) : I have 

been doing psychiatry for about sixteen years and 
before the advent of malaria therapy whenever a 
patient had paresis we considered it hopeless. 
When anyone made a statement that he had cured 
a case of paresis he had to do some talking to 
convince the listener. I cannot see the danger 
of malaria therapy nor do I believe all this bug- 
bear about patients dying from this treatment. 
Down here we know more about the treatment of 
malaria, which probably accounts for our lower 
mortality rate. I never lost a case of tertian 
malaria in my life and before inoculating with 
malaria never had a case of paresis get well. 
Of course, if you take the late cases where there 
has been a great deal of destruction and give 
them high temperatures, they will probably die. 
It is the selected early case that gives the best 
results. I was visiting St. Elizabeth’s, in Wash- 
ington, D. C., and had a talk on this subject with 
Dr. White. He has inoculated probably 50 to 75 
cases with good results. 

Just a few words about the patient Dr. Uns- 
worth presented tonight. When I first saw him 
he was much excited, busily engaged in buying 
up rice mills and building homes — expansive ideas 
and exalted. Laboratory study showed increased 
globulin, a paretic curve and a four plus Was- 
sermann. You now see him as an apparently 
perfectly normal individual, supporting a wife and 
five children. What difference does it make what 
you have in your spinal fluid if you can make 
a living? I have never seen a paretic adjust 
himself, economically and socially, as this man. 
In other treatments the gain is not so marked, 
either economically or socially. I believe in these 
cases where the treatment is properly carried out 
we are going to have a great future. I have 
had but ten or twelve patients. One Dr. Johns 
inoculated had teperature of 104°. We will pre- 
sent him in a couple of weeks greatly improved. 


172 


Unsworth — Malaria Therapy in Paresis 


Dr. Connely (New Orleans) : Dr. Unsworth 

is to be con^atulated on his work. Any treat- 
ment that will help paresis is to be grasped at 
and tried out. Some two and a half years ago 
I had occasion to look over cases at St. Eliza- 
beth’s in Washington and some of their results 
were sensational. At that time the attitude of 
the men doing the work was hopefully skeptical 
— some still maintain that attitude. I think that 
probably it is best, for while at present it is 
probably the most hopeful treatment that we 
have, nevertheless, I am inclined to agree with 
Dr. Kimball, that we may be a little too enthusi- 
astic over it. 

Dr. Holbrook’s caution in regard to being sure 
that we are treating paresis is well taken. It 
is a common idea that almost any type of cere- 
bro-spinal syphilis should be treated with malaria. 
I do not know if Dr. Kimball has had cases of all 
sorts coming from long distances for this treat- 
ment. I had one from Los Angeles, a typical 
case of cerebro-spinal syphilis. 

Dr. Kimball has placed his finger on the main 
trouble in judging accurately the value of this 
therapy in paresis, viz: lack of accurate statistics 
and the length of time necessary to find out 
whether the benefit is transitory or permanent. 

Dr. W. H. Seeman (New Orleans) : I saw this 
young man in an attack and had to use all the 
influence I could to induce him to let me do a 
spinal puncture. He was anxious at the time to 
purchase the whole of New Orleans. It happened 
I had treated his family, so I succeeded in get- 
ting him to postpone the big deal long enough 
to allow me sufficient time to do a spinal punc- 
ture. 

We know that in paresis the mortality has 
been 100 per cent, so granting on the one hand 
that we take a chance by inoculating a patient 
with tertian malaria, on the other hand we are 
giving him an opportunity to get well. I was 
very much impressed with an article in the A. 
M. A. Journal giving the mortality in treated 
and untreated paresis: in the untreated cases the 
death rate was 58 per cent in one year; in those 
where malaria therapy was employed the mortal- 
ity rate was 10 per cent. 

It would seem, therefore, that this method of 
treatment does not add much danger or gravity 
to the situation. 

Dr. Isham Kimbell (U. S. Veterans’ Hospital, 
Gulfport, Miss.) : I have been studying the treat- 
ment of paresis by inoculation with malarial blood 
for several years (about four years) and I am 
not quite as enthusiastic about it now as when 
I first began. It has its advantages and disad- 
vantages. I have seen some very remarkable re- 


sults in the treatment of paresis by this method, 
but I do think that we should be conservative 
about this method of treatment and keep accur- 
ate records of our cases, tabulating all our find- 
ings, details of treatment, outcome, etc., so that 
we may have some reliable information. 

In studying these patients we have outlined a 
system for recording the data in each case. We 
like to know the length of time the patient has 
been under observation, the preliminary treat- 
ment, if any; the amount of malarial blood inoc- 
ulated and whether administered intravenously, 
subcutaneously, or intramuscularly; the reaction, 
if any; the incubation period; further observa- 
tions and any complications; the effect of treat- 
ment on the serology, including the cell count, 
its effect on the globulin content and colloidal 
gold, and the ultimate result of this treatment. 
In the event of death, if the body is autopsied, 
the accurate necropsy findings should be reported. 
If we standardize our work to show what we 
have done and compare it with the work of other 
investigators, we will derive some information 
which will prove of assistance to us in ultimately 
determining the value of this form of treatment. 
I have three groups of cases which are interest- 
ing. The first group consists of 7 patients who 
have been under observation for a period of 
three years; the second group, 27 patients who 
have been under observation sixteen months, and 
the third group, 38 patients, six months. In the 
first group, all the patients were advanced pare- 
tics. The second group were showing consider- 
able dementia. Of the third group, 4 were de- 
mented, 12 were actively psychotic (six mildly 
so), 16 were early cases, and 6 late cases with 
some euphoria. 

Of the first group, none died during treatment 
and none have died following its completion. 
Three are slightly improved, four much improved 
— all are living at this time. All of these patients 
were at some time disturbed, necessitating con- 
finement on locked wards. There were some 
complications in these groups; nausea, vomiting 
and hyper-pyrexia were later serious complica- 
tions and because of persistent nausea one pa- 
tient could not take quinine by mouth. Seven 
patients were inoculated by the subcutaneous 
method, the others intravenously. The period of 
inoculation was from six to twelve days, the 
paroxysms ranged from five to sixteen. An atyp- 
ical or irregular course of temperature was the 
rule. One patient had a chill and a rise of tem- 
perature every 24 hours throughout the attack; 
there were free intervals ranging from five to 
ten days, but these were no.t succeeded by parox- 
ysms of greater intensity, neither could plasmodia 
be demonstrated in the blood at all times. Fre- 
quent examinations of the blood were made and 


Uns WORTH — Malaria Therapy in Paresis 


173 


the number of parasites per 100 fields noted. 
Some investigators have reported that the in- 
tensity of the paroxysms is not dependent on 
the number of parasites per field, but it v/as in 
our cases. In one case there was improvement 
for three months after inoculation, then the pa- 
tient began losing weight and he became worse 
mentally. A second inoculation was then done 
and following this patient gained weight, his gen- 
eral condition improved and it was not necessary 
to retain him on the locked ward. This patient 
was also given intensive anti-syphilitic treatment. 
All of the original 7 cases were inoculated twice, 
some of them three times; the last two attempts 
to inoculate the original 7 cases failed. Four 
of these cases in the first group are on an open 
ward, two are on closed wards and one has re- 
turned home to his work. Twelve of the patients 
in these groups who received the inoculation ma- 
laria treatment are now maintained on closed 
wprds. Of these twelve cases, one is disturbed 
but his physical condition is good, seven are very 
much deteriorated, three are improving and may 
become open ward cases. Of those on locked 
wards, three are of the original 7 under observa- 
tion; five are of the third group under observa- 
tion six months, and the others are from group 
No. 2 who have been under observation sixteen 
months. Eighteen patients have returned home 
and have resumed gainful occupations. Twenty- 
two are engaged in active out-door work on the 
farm and they may eventually return to their 
homes. Nine have travelled a long way “on the 
road to dementia” and one seems hopeless and 
will probably die of paresis. Two cases died dur- 
ing the treatment, one from pneumonia, and the 
other following an epileptiform seizure. It has 
been our observation that demented types show- 
ing decided mental deterioration do not improve 
and that the manic or expansive types do im- 
prove. One patient who had been treated by 
inoculation with malaria blood and had been un- 
der observation several months developed acute 
mastoiditis which required mastoidectomy. This 
patient was one of the worst cases you could 
possibly see, he was filthy in his habits, would 
chew up his bed clothing, tear up his pajamas, 
and had to be kept in restaint at times. He im- 
proved very rapidly after he recovered from his 
mastoid infection and has returned home and 
has resumed his former occupation. One patient 
under our observation had a remission following 
an attack of pneumonia. 

As to the changes in serology. 

In the first group, all have negative Wasser- 
mann reactions on the blood and spinal fiuid, 
the gold curve is negative, in 5, modified in 1, 
and unchanged in 1. In the second group, the 


blood and spinal fluid is negative in 7, the blood 
is negative in 15 cases, and the spinal fiuid is 
strongly positive in 5, and weakly positive in 10 
cases. In the third group, the blood Wassermann 
is definitely negative in all execept 6 cases, re- 
maining strongly positive in these. 

The study of the spinal fluid has not been com- 
pleted in the last group. 

Just exactly what the histo-pathology is in each 
one of these cases which we have diagnosed as 
paresis we are unable to state. The pathology of 
general paralysis of the insane has been clearly 
outlined by competent pathologists and we can 
now accept this outline as definite and indispu- 
table. Do we sometimes report cases of diffuse 
interstitial cerebral syphilis as cases of paresis? 
Do we sometimes confuse other forms of neuro- 
syphilis with paresis?. There is food for thought 
here. Let us get as many complete and accurate 
necropsy reports as possible before we make our 
final conclusions as to the efficacy of this form of 
treatment. 

I thank you. 

Dr. H. R. Unsworth (closing) : Personally, I 

have had no mortality. My conclusions have been 
drawn mostly from observation and contact with 
the literature. You have to believe what you 
see. You saw tonight. I do not think there is 
any better proof that malaria is worth while than 
this one case brought here to demonstrate its 
value. 

There is a very definite thing everyone knows, 
that is, that clinical symptomatology does not run 
to the serological reactions will all be negative. 
It is a year, or longer, before you can expect 
any change in your serology. I personally have 
hertofore always accepted paresis as the terminal 
stage in cerebro-spinal lues. In microscopic exam- 
ination of the paretic brain following malaria 
therapy they are unable to demonstrate any pa- 
thology; it seems to me that the same thing must 
hold good in cerebro-spinal lues. I have seen 
some very definite, purely psychic, results in pa- 
tients who were paretics; I believe your improve- 
ment is definitly psychic, that your result is in 
the psychic field and not organic. Your man 
who was not oriented, under malaria treatment 
becomes oriented. 

I am perfectly enthusiastic about this therapy 
and to my mind it is certainly the treatment to 
employ in paresis. The earlier it is given the bet- 
ter the result. It is quite obvious that if you 
take an individual with deterioration and inocu- 
late him with an acute disease you are going to 
kill him occasionally. 


174 


Musser — The Problems of Uremia 


THE PROBLEMS OF UREMIA.* 

J. H. MUSSER, M. D.,t 
New Orleans. 

Before undertaking to discuss with you 
the clinical and the etiologic problems of 
this disease, not to mention the unusual 
findings that we get from the study of 
blood chemistry and the urine, I think it 
might be well to define just what is under- 
stood by uremia. The general conception 
of this term is that it is a peculiar psycho- 
motor disturbance characterized by certain 
symptoms which are toxic in origin. This 
definition applies to the type of uremia 
which we usually picture in our minds as 
being uremia, but I should prefer to make 
my definition even more broad than this 
and include in it types of response of the 
human organism to any failure of the 
kidney function. This certainly is a most 
inclusive definition and will allow and 
permit of a rather broad discussion. 

If I then define uremia as an intoxica- 
tion caused by renal dysfunction, it might 
be well to mention the functions of the 
kidney which are disturbed as a result of 
nephritis, in the majority of cases, but 
which may be disarranged by some condi- 
tion which has no bearing whatsoever upon 
inflammatory or proliferative changes in 
the kidney such as we see when we have 
urinary suppression secondary to prostatic 
obstruction. 

The primary functions of the kidney are 
five in number : 

1. Secretion of water. 

2. Elimination of waste products by 
nitrogen metabolism. 

3. The maintenance of optimum con- 
centration of salts in fluids and 
tissues. 


*Read by invitation before the Mississippi 
State Medical Association, Meridian, Miss., May 
9 , 1928 . 

t(From the Department of Medicine, Tulane 
University School of Medicine.) 


4. The elimination of acids. 

5. The excretion of toxic materials ar- 
tificially introduced. 

The simplest of these functions is the 
excretion of water, the normal individual 
passing from 1,000 to 11,500 cc. in 24 hours. 
The waste products of nitrogen metabo- 
lism include those substances — urea, uric 
acid, creatinin, which we find of value in 
determining, by blood chemical methods, 
their percentage quantities in a given 
amount of blood. The kidney is able to 
excrete in the urine by a process of con- 
centration enormous quantities of urea 
and other waste products. The concentra- 
tion in the urine may be seventy-two times 
that of the blood. However, if this ability 
to concentrate is lost, as it is in many cases 
of nephritis, we find a piling up of these 
waste products in the blood, recognized by 
certain clinical symptoms which are often 
very hazy and indefinite, as well as by an 
examination of the blood. The third func- 
tion of the kidney has to do with the 
proper balance of salts, of which sodium 
chloride is by far the most important. 
Normally the kidney is well able to do 
this, excreting an excess of chloride and 
maintaining in the blood a uniform con- 
centration of this salt. If this particular 
function of the kidney fails, however, we 
have salt accumulating in the tissues, as 
the concentration of the blood is remark- 
ably stable, and to maintain the proper 
osmotic pressure fluid goes into the tissues, 
producing edema. The fourth function of 
the kidney is an important one. Acids are 
formed during the process of metabolism. 
By its action with buffer salts, the kidney 
is able to excrete large quantities of acids 
in the course of a day — 60 to 70 cc., or 
expressed somewhat differently, from 3 to 
31/2 grams of sulphuric acid each day 
passes through the normal kidney. If this 
does not happen, we have a condition of 
acidosis which, however, never attains the 
degree of severity which characterizes the 
acidosis of diabetes, for example, in which 


Musser — The Problems of TJr&mia, 


175 


condition abnormal acids are formed in the 
body. The last function of the kidney is, 
of course, an extremely important one and 
yet it is one which does not manifest itself 
very frequently clinically. One of the 
misfortunes of this organ is that this par- 
ticular function may often be very harm- 
ful and dangerous to it. The elimination 
of streptococci and other products pro- 
duces inflammatory changes. The excre- 
tion of mercury will cause a severe 
nephritis and often death. 

In uremia these various functions of the 
kidney are disturbed and disturbed in 
many and numerous ways. Just why the 
various symptoms should appear we can- 
not always say, nor can we attempt to 
prognosticate just when such symptoms 
may appear. Furthermore, it is impossible 
in the majority of cases to correlate the clin- 
ical syndrome with the pathologic picture 
and, lastly, we are unable to state just 
what is the ultimate and basic cause of 
uremia. Various theories have been ad- 
vanced, the earliest one, of course, being 
that urea is retained in the blood, but we 
know that urea alone is not capable of pro- 
ducing the symptoms of uremia and we 
know also that uremia occurs without 
marked nitrogen retention. While it is 
true that urea in excess does not produce 
the symptoms of uremia, nevertheless it is 
quite possible that there might be increased 
concentration of the other nitrogen waste 
products, such as creatinin and uric acid. 
There is also the further possibility that 
there may be more complex fractions of 
the non-protein nitrogen in the blood 
which may be responsible for the condition. 
The possibility of decomposition products 
of these nitrogenous retention materials 
has been suggested, but, on the other hand, 
these have never been shown to be toxic. 
It is possible that uremia may be due to 
disturbance of internal secretion of the 
kidney or to the sending into the circula- 
tion of toxic material from disintegrated 
kidney cells. Phenol derivatives have also 
been suggested. In certain types of uremia. 


spoken of as the moist type, very 
frequently the symptoms may be due to 
cerebral edema, as is seen in the so-called 
moist type of uremia. The one definite 
positive information that we have has come 
from the researches of Nellis Foster, who 
has been able to isolate from the blood of 
uremic patients who had the convulsive 
type of uremia, a crystalline substance 
which when injected into animals could 
reproduce the psychoneuromotor syn- 
drome of uremia. This certainly repre- 
sents a type of uremia which is due to 
some abnormal product of metabolism. 

From the clinical point of view we are 
accustomed to divide uremia into three 
main types — the one associated with 
marked nitrogen retention associated with 
psychoneuromotor symptoms and often 
spoken of as the dry type of uremia; and 
the moist type without marked nitrogen 
retention but with a retention of chlorides. 
Lastly, we have the type in which the 
toxic substance of Foster has been found. 
This manifests itself chiefly in epilepti- 
form-hke convulsions. The first two types 
are just as much uremic in their origin 
and manifestation as is this third type 
which presents the classic picture of 
uremia. The type with nitrogen retention, 
seen probably more beautifully in mercury 
poisoning than in any other one condition, 
presents none of the outstanding features 
of uremia. These patients frequently go 
off into a quiet sleep after becoming more 
and more comatose and at no time have 
any unusual complaints. This is illustrated 
very well by a patient, J. P., a young 
woman, aged 27, who took three one-half 
gram tablets of bichloride of mercury. 
The patient, after the preliminary vomit- 
ing and purging, apathetically lay in bed, 
was quiet, but talked until the eleventh 
day of her disease, when she sank into a 
coma from which she could not be aroused, 
and she died within two hours. The moist 
type of uremia, likewise, does not show 
any very unusual symptoms suggestive of 
renal insufficiency in a sense that we have 


176 


Musser — The Problems of Uremia 


psychic and nervous manifestations. 
Extreme edema of the brain produces 
somnolence and then sleep. Illustrative of 
this type is the case of Mrs. M. M., an old 
lady of 65 years of age, who was admitted 
to the hospital during a period of uncon- 
sciousness, which when she was aroused 
from was not accompanied by any prelim- 
inary signs or symptoms. Blood pressure 
was not unduly raised, non-protein nitrogen 
was not unduly high, phthalein elimination 
was good. Urine showed a considerable 
amount of albumin, fairly high specific 
gravity, numerous casts. Another case is 
that of Mrs. P. T., who came into the hos- 
pital with rather pronounced anasarca. 
This patient also had marked increase in 
her blood pressure, some cardiac enlarge- 
ment, stupor, fairly high non-protein 
nitrogen, in the urine a large amount of 
casts and great quantities of albumin, to- 
gether with a phthalein elimination which 
varied between 15 and 25. While in the 
hospital she several times became ex- 
tremely stuporous and had numerous 
attacks of paroxysmal dyspnea. She repre- 
sents the moist type and shows quite 
clearly that there can be no absolute and 
definite, clearcut delimitation of the one 
type from the other. J. M. S., on the other 
hand, 45 years of age, was admitted to the 
hospital with convulsions which came on 
suddenly. This patient had failure of 
vision, blood pressure of 210/160, a low 
non-protein nitrogen, never above normal 
figures, specific gravity which was inva- 
riably low, a fair degree of albumin and a 
low phthalein elimination, which increased 
from 18 per cent on admission to 55 per 
cent at the time of his discharge. This 
patient was the convulsive type of uremia, 
yet she had physical examination and 
urinary findings which were rather un- 
usual for a condition with outstanding 
manifestations such as this convulsive 
type. 

The Manifestations of Uremia. I have 
given three histories briefly rather from 
the point of view of illustrating severe 


types of uremia rather than to call atten- 
tion to the manifestations of the condition. 
These are so obvious that they would not 
be likely to occasion much difficulty in 
diagnosis. On the other hand, employing 
the broad definition that we have given for 
uremia, a tremendous number of patients 
are observed with symptoms which are un- 
doubtedly due to the effects of kidney 
insufficiency and for that reason are really 
manifestations of uremia. 

Urinary Symptoms. Given a patient 
with indefinite, irregular, vague and atypi- 
cal symptoms, it is wise always to suspect 
uremia. The first study that is made after 
the history has been taken and physical 
examination has been completed would be 
the examination of the urine. Here we 
find tremendous discrepancies which are 
often puzzling and indefinite. Albumin 
may be present in large quantities or it 
may be absent. Casts may or may not be 
present. I have seen patients with marked 
edema give a normal phthalein output. 
Why we should get these marked varia- 
tions in the urinary symptoms is one of 
the puzzles of this condition. 

Psychoneuromotor Symptoms. The psy- 
choneuromotor symptoms are of great 
importance in the diagnosis of uremia. 
The psychic syndrome is on the whole de- 
cidedly more important than is the 
neuromotor. The psychic symptoms may 
range from a low grade delirium to pro- 
nounced excitable states. At times the 
patient suffers from hallucinations. At 
other times they may be stuperous or even 
comatose. Delirium at night is fairly 
common and insomnia is a distressing 
symptom even in those patients who are 
most stuperous. The nervous manifesta- 
tions include attacks of paraplegia or 
hemiplegia, asphasia, neuralgias and head- 
ache. Of these neuromotor symptoms, 
most interesting are those associated with 
transient loss of power in the extremities 
or with aphasia. Oftentimes this phenom- 
enon is extremely short and may disappear 


Musser — The Problems of Uremia 


177 


in an hour or two. At other times it may 
last for twenty-four hours. Headache is 
one of the annoying symptoms. This is 
almost invariably present and at times 
reaches a high degree, causing intense 
suffering of the patient. The uremic neu- 
ralgias are fairly common. I have seen 
pain in various parts of the body explicable 
only upon this basis. 

Respiratory Symptoms. Cheyne-Stokes’ 
respiration is extremely frequent, but it is 
found in a good many other conditions. 
Paroxysmal dyspnea seen at night is in the 
same category, but true pumonary edema 
may be said in many cases to depend 
entirely upon impairment of kidney 
function. 

Cardiovascular Manifestations. Hyper- 
trophy of the heart and high blood pres- 
sure are a constant finding in the most 
frequent type of nephritis — namely, the 
chronic nephritis without edema. In other 
types of nephritis these findings are not 
always observed, but because of the fact 
that the chronic type without edema is so 
common, we are accustomed to associate 
the high pressure and hypertrophy of the 
heart with uremia. It is quite compatible 
with having true uremia to have a low 
blood pressure. Riesman* reports a case in 
which the systolic pressure was only 84. 

Ocular Symptoms. In many cases our 
diagnosis of uremia can be made only upon 
correlation of the whole symptom complex. 
One of the most important examinations 
to be made is the use of the ophthalmo- 
scope which may show many changes 
which are essential in building up the 
clinical picture. The occurrence of choked 
discs, neuroretinitis and exudates on the 
retina may be findings which will finally 
determine the nature of the condition. 

The Prognosis. It is impossible to tell 
what the ultimate outcome will be in 
patients who present the subjective and 

(Riesman, David R., Southern Med. Jour., 16:160, March, 
1923.) 


objective phenomena of uremia. The in- 
dividual who develops uremia as a result 
of urinary suppression from a large pros- 
tate, for example, may live on for years 
after the condition which caused the sup- 
pression has been removed. The patient 
with symptoms of uremia following scarlet 
fever may entirely recover and never have 
a sign or symptom afterward indicative of. 
renal insufficiency. Even in fairly ad- 
vanced and well marked cases of nephritis, 
the patient may live for years. I have in 
mind a far advanced cases which I have 
followed for three years. E. B. came under 
my observation early in 1925 when he was 
brought into the hospital because of sud- 
den unconsciousness. He had a blood 
pressure of 230/150. He was in coma for 
forty-eight hours and then came out of it. 
His non-protein nitrogen was high, albu- 
min was 9 per cent, phthalein elimination 
20. On and off for the next three years 
he came into the hospital for a short time 
on account of headache or because he had 
been picked up unconscious. His eye were 
almost blind and he had extremely high 
pressure, yet, except for these annoying 
attacks of unconsciousness he was able to 
carry on and make his living. When he 
was finally brought into the hospital a few 
weeks ago he developed urinary suppres- 
sion from a large prostate and died in the 
course of a few days. 

Treatment. It hardly seems advisable 
to go into a detailed discussion of the 
treatment of uremia. It boils down to two 
main features. First, remove the cause, if 
possible. If, unfortunately, it is not pos- 
sible to remove the cause, then encourage 
elimination by the drinking of large quan- 
tities of water, free purgation and some- 
times sweating. There are one or two 
features in the treatment that I would 
suggest should not be overlooked: First, 
diet; second, venesection; third, diuretics. 
The diet should be plain and non-irritating. 
Milk is the food that can best be taken 
and its value may be enhanced, when the 
patient’s stomach is extremely irritable, by 


178 


Musser — The Problems of Uremia 


adding carbonated water. Cereals are of 
value and they should be well sweetened in 
order to get the caloric effect of the sugar. 
Well sweetened fruit juices are also advis- 
able to give the patient and sometimes can 
be retained when milk cannot. Under any 
circumstances, as soon as the patient has 
recovered from his acute manifestations of 
uremia, do not be afraid to give him 
plenty of food and always give a sufficient 
amount of protein food without fear. 
Nitrogen equilibrium may he obtained with 
approximately a gram of protein per kilo 
of body weight. 

Venesection. In active uremia, venesec- 
tion is incomparable. For the patients 
with the severe headaches without any 
other psycho-motor symptoms, venesection 
is also of value. That same thing applies 
to the individual with high blood pressure. 
In these cases rather frequently repeated 
small venesections are best adapted. For 
the extremely severe headaches which does 
not respond to the ordinary forms of treat- 
ment, I have found lumbar puncture ex- 
tremely valuable. 

Diuretics. A word about these much 
abused preparations. Keep away from 
them. Their action on the kidney in the 
great majority of cases is primarily a 
stimulation followed by secondary ex- 
haustion. Their beneficial effect is ex- 
tremely temporary and their after effect 
is usually markedly deleterious. Under 
no circumstance would I recommend their 
employment. 

DISCUSSION. 

Dr. W. A. Dearman (Gulfport) : I deem it a 

privilege to have an opportunity to discuss this 
classical paper of Dr. Musser’s. He has very 
clearly enunciated the etiology of types of uremia 
that may come under our vision, and the blood 
changes as well as the urinary findings. There 
is no question but what many a man has died 
of uremic coma with a normal blood history and 
a normal urinalysis. It is puzzling and baffling 
sometimes to have to think of this. I am glad 
to hear Dr. Musser condemn diuretics in uremic 
cases of any kind. I have a patient who, before 
I saw him, had been to a neurologist. He was 
completely blind because of retinal edema. Dr. 


Musser brought out, I remember, clearly the 
cerebral symptoms. However, a few nights ago 
a patient was in rather a comatose state, violent 
headache and occasionally some nausea and vom- 
iting, and a Cheyne-Stokes respiration. I found 
him nervous, under the influence of morphin, and 
I suggested to the doctor with whom I was in 
consultation, that he discontinue the opiate and 
his respiration cleared up promptly. I saw that 
also in a child. Dr. Musser also condemned, as 
I say, the diuretic treatment. It will not do to 
stimulate and inflame the kidneys, for they are 
not functioning well any way. They are doing 
all the work they can possibly do. To stimulate 
them further is not unlike whipping a horse after 
it had fallen in the road completely exhausted. 
I have a patient now who had been taking 15 
grains of pmorphin for sometime, and enough 
poison was being eliminated into his kidneys to 
set up an exacerbation of a pre-existing nephritis. 
They had given him 30 minims or about 2 cc. of 
spirits of nitre every hour and a half, and they 
added to that, which was about the last straw to 
break the camel’s back, 15 drops of spirits of 
turpentine every four hours, and were doing that 
for four days. He was as blind as a bat. I pre- 
sume he is dead now, I don’t know. 

The uremic state will offer a complex occa- 
sionally. They are usually well delineated or 
clear in the minds of men from investigation. 
Dr. Musser brought out the importance of the 
eye being carefully examined. This is very im- 
portant, indeed, and will even give you a clue to 
what is going on when other symptoms are in 
doubt. There are certain defined conditions in the 
fundi which will lead us to an accurate diagnosis. 
I see much cerebral arteriosclerosis, sometimes 
with retinal changes closely similating those of 
the uremic state. I think this paper very illum- 
inating and one that is timely. 

Dr. W. W. Crawford (Hattiesburg) : Mr. 

Chairman and Gentlemen: We have not gotten 

away from our appreciation and veneration for 
our professors. When I was a student in Phila- 
delphia I used to hear Dr. Musser at the Univer- 
sity of Pennsylvania on rare occasions, and I was 
quite impressed with his astuteness as a teacher 
of medicine, and today it is my privilege to stand 
up and discuss a paper by his honored son. We 
are very glad indeed to number among the 
teachers of medicine in the South, Dr. J. H. 
Musser. It goes without saying that his contri- 
bution to this program today is replete with 
valuable information. It is further apparent that 
any discussion on my part would lend nothing to 
the information to be acquired from this paper. 

I was very glad to hear Dr. Musser say that 
uremia is a rather will-o-the- wisp-sort of thing. 
You can’t put your finger on it. You see things 


Musser — The Problems of Uremia 


ITd 


that it does to the body, but you are not so sure 
from what particular chemical source they are. 
Dr. Bourchard, you will remember years ago, 
demonstrated that a patient might have uremia 
for several days and yet not develop uremic 
symptoms, certainly not uremic coma, which means 
of course that that thing we denominate uremia 
did not operate in that particular patient’s ex- 
perience. Of these cases of uremia that we 
constantly see, cases in which the uremia is a 
chronic manifestation, particularly those compli- 
cated by hypertension associated with nephritis, 
we may say that we have a condition that can- 
not be rectified, and therefore we must be ever 
on guard to keep our patient in the best possible 
condition if he is to live for a number of years. 

Speaking of the surgical aspects of uremia, a 
great many patients come into serious trouble in 
the surgeon’s hands, if the surgeon fails to recog- 
nize the necessity of estimating the functional 
capacity of the kidney before operating. Time 
and again we have seen patients who were secret- 
ing an adequate supply of negative urine, and yet, 
when we made a real functional test, we would 
be apprised of the fact that the kidney wa? totally 
incompetent, and that if an operation of any 
special moment with ether anesthesia was done 
on such a patient, we should have regretted it. 

We are coming to appreciate in surgery more 
and more the importance of a pre-operative prep- 
aration of our patients, and there is no factor 
that is so significant as the recognition of this 
question that leads to the condition that you call 
uremia. Just so surely as we operate on a patient 
with a low renal function test, just so surely shall 
we get into trouble. Unfortunately, when you 
recognize the fact that the kidney is incompe- 
tent, however urgent the operation may be, it is 
best to let it along. Time and again have we 
had occasion to say to a patient who should have 
surgery, that we can not afford to operate because 
of the fact that there is an incompetent kidney. 
I enjoyed the doctor’s paper very much and want 
to congratulate the Mississippi State Medical 
Association on having him as its guest. 

Dr. L. iS. Lippincott (Vicksburg) : I have en- 

joyed this paper very much. Nephritis in general 
is one of the most important subjects and I would 
like to ask Dr. Musser, if I may, what signifi- 
cance he puts on the retention or non-retention of 
uric acid in kidney disease, particularly in uremia. 
We were taught at one time that uric acid was 
the first of these products to be retained, and at 
that time we thought it was very important that 
we get back at early kidney disease. It has not 
worked out so. It is not an early product and 
it isn’t always a later product. I would appre- 
ciate very much the doctor’s opinion on that. 

Dr. J. H. Musser (closing) : First, I want to 

express my appreciation to you for inviting me 


here today, and giving me an opportunity of 
talking to this splendid body of men. I thank 
Drs. Dearman, Crawford, and Dr. Lippincott also, 
for their points of discussion. In regard to the 
question Dr. Lippincott asked, I think that uric 
acid is to a certain extent a sign of some value. 
You can not say definitely and positively about 
it. The test of uric acid is somewhat a bad 
prognostic import, I think, of kidney insufficiency, 
but it is not absolute. 

The question of protein is rather important. 
It is necessary to maintain the equilibrium, and 
to do that, you have to give nitrogen a certain 
quantity of protein. The protein should be 
given by the mouth and should be sufficient to 
keep a normal equilibrium between the intake and 
the output, so don’t be afraid to give a certain 
amount of protein in your therapy. It is quite 
essential. I wanted to call attention to the fact 
that a few years ago efforts were made exten- 
sively to classify types of nephritis according to 
the different types of anatomic lesions in the 
kidney. I have been following Dr. Henry Chris- 
tian’s classification of nephritis rather exten- 
sively, and that is a classification which is based 
entirely on clinical symptoms, chronic nephritis 
with edema or without it. It is a very simple 
classification and one which I think is of great 
value because it does not attempt to make this 
differentiation between different portions of the 
kidney which are involved. It gives us rather a 
clear cut easily recognized clinical picture. Again 
want to thank you very much. 


USE OF MERCUROCHROME AS VAGINAL ANTISEP- 
TIC IN INDUCTION OF LABOR. — Evidence is presented 
by Harry Welday Mayes, New York, to show that when 4 
per cent mercurochrome-220 soluble is used' as a vaginal 
antiseptic prior to the induction of labor, the safety of the 
hydrostatic hag is greatly enhanced. For two and a half years 
the use of mercurochrome as a vaginal antiseptic has been 
adopted as a routine procedure at the Methodist Episcopal 
Hospital, and there have been 3,500 deliveries with an uncor- 
rected morbidity of 8.6 per cent. In a series of ninety-three 
induced deliveries in the period from 1917 to 1924 there was 
a morbidity of 29 per cent, with an average of 2.08 days 
of morbidity for each patient. In this series there were 
eight maternal deaths, a mortality rate of 8.6 per cent. 
For the years 1917 and 1919 the morbidity rate was 40 per 
cent. Since the routine use of mercurochrome for all de- 
liveries was instituted, seventy-eight patients have been de- 
livered after the induction of labor by means of the hydro- 
static bag. During that time, the morbidity has been 11.5 
percent as compared with that of 29 per cent in the earlier 
series; that is, 60 per cent less as compared with the mor- 
bidity without mercurochrome. At the same time, the mater- 
nal mortality has been reduced from 8.6 per cent to 1.3 
per cent, and the average period of morbidity from 2.08 
days to 0.57 days. — J. A. M. A., Nov. 12, 1927, p. 


180 


Pack — The Complications of Cancer 


THE COMPLICATIONS OF CANCER.* 
GEORGE T. PACK, M. D.f 
Birmingham, Ala. 

The complications of cancer are of 
timely interest because: (a) The initial 

symptoms of certain cancers are heralded 
by the onset of complications, (b) most 
cancerous individuals die from complica- 
tions, rather than the natural progress of 
the disease, (c) complications form the 
most important barrier to the successful 
treatment of malignancies. In this short 
resume, no attempt will be made to discuss 
the signs and symptoms of cancer of any 
particular organ, nor will the nature and 
distribution of metastases be considered. 

THE LOCAL COMPLICATIONS. 

MECHANICAL CONSEQUENCES OF THE 
PRESENCE OF CANCER. 

The mechanical disorders induced by 
volumetric increase of a malignant neo- 
plasm are no different than those produced 
by benign tumors. Epitheliomas and 
gliomas of the brain give the same syn- 
dromes of intra-cranial hypertension as 
do cysts and fibromas; cancer of the pros- 
tate provokes the same troubles as simple 
adenomatous hypertrophy, plus the subse- 
quent effect of infiltration. 

By the time a cancer has caused stenosis 
sufficient to evoke symptoms, it is very 
late in its course. It is only rarely that 
absolute stenosis with complete obstruction 
of a visceral lumen is seen, as in the 
esophagus, pylorus and Vaterian ampulla. 
As a rule the lumen of any canal, which is 
infiltrated by neoplastic tissue, is a patent, 
rigid, inextensib'le ulcerated tube. The 
perverted functioning of the part, ex- 
pressed as recognizable symptoms, is 
usually due to immobility and an accom- 
panying spasticity. 

*Read before the Alabama State Medical Asso- 
ciation, Birmingham, Ala., April 18, 1928. 

fFrom the department of Pathology, School of 
Medicine, University of Alabama, Tuscaloosa, 
and The Seale Harris Clinic, Birmingham. 


The orificial stenoses are more commonly 
caused by infilitrative growths than by 
enormous and occluding vegetations. For 
instance, scirrhous growths of the recto- 
sigmoidal junction cause obstruction 
earlier than the bulky, exophytic, vege- 
tating tumors of the rectal ampulla. 

TROUBLES OF DEFICIT. 

Troubles of true deficit due to loss of 
function, because of massive destruction 
of organs by cancer, are infrequent. Only 
a very small portion of liver, kidney 
(1/10), thyroid and pancreatic (1/8) sub- 
stance suffices for the maintenance of nor- 
mal function. This offers the explana- 
tion why myxedema is uncommon in 
thyroid cancer and why diabetes practi- 
cally never occurs as a result of pancreatic 
malignancies. 

ULCERATION. 

The appearance of an ulceration is a 
critical event in the history of any cancer. 
The ulcerated cancer is then no longer a 
latent affection. A new phase begins, 
which is rich in the possibilities of acci- 
dents and symptom-provoking events. This 
is the opportune moment to issue an ad- 
monishment against biopsy of a tumor, 
when the superficial mucous membrane is 
unbroken, as in such locations as the rec- 
tum and bronchus. 

Ischemic necrosis and infection are the 
two chief factors which concur in the for- 
mation and in the incipiency of neoplastic 
ulcerations. The neoplastic tissues are 
frequently fragile; they are more vulner- 
able to nutritional impairment and irrita- 
tions than normal tissues. When tumors 
acquire certain sizes, foci of degeneration 
appear in edematous and hemorrhagic 
zones. 

The inflammatory lesions which accom- 
pany the neoplasia are generally greatest 
at the periphery. In mucosal cancers of 
the digestive tube in particular, the inflam- 
mation of the mucosal wall is infinitely 
more extensive than the tumor itself. The 
inflammatory infiltrations are subacute; 


Pack — The Complications of Cancer 


181 


at the periphery, the reaction is prolifera- 
tive and sclerotic, but on the surface it is 
necrotic, degenerative and suppurative. 
The ulceration is, properly speaking, an 
ulceration of tissue invaded by a cancer. 
This submucosal extension of cancer and 
inflammation together is especially noticed 
among cancers of the stomach, esopliagus 
and large intestine. 

Cancers which begin on the surface, as 
the carcinomas of the skin and mucous 
membrane, commonly ulcerate early. For- 
tunately malignant skin ulcers have usually 
a torpid growth. The ulceration is 
frequently contemporary with their initial 
appearance. However, some deep neo- 
plasms of the skin may propagate early 
by metastasis and remain covered by intact 
epidermis for a long time. 

The simple chronic ulcers and cancerous 
ulcers of the stomach resemMe each other 
so much at times, that they are frequently 
the cause of regrettable confusion. In cecal 
disease, the eye of the surgeon can dis- 
tinguish the thick infiltration and blanch- 
ing of the obvious cancer, and the tuber- 
cles, peritoneal nodosities and irregularly 
ulcerated mucosa of advanced tuberculous 
cecitis. But in other instances, a histo- 
logical study alone demonstrates with 
certitude the true nature of the process. 
Analagous difficulties exist in the interpre- 
tation of rectal ulcers. Ulceration of 
tumors of the breast, tongue, floor of 
mouth and cervix uteri merit weighty con- 
sideration and concern. 

THE INFECTION OF CANCERS. 

Ulceration opens the portal of entry for 
organisms. This is unfortunate. Ewing 
has observed that tumor cell mitoses are 
much more numerous in an infected part 
of a tumor than in a non-infected part of 
jthe same tumor. Pyogens and saprophytes 
jof all orders complicate the ulcerative 
; lesions of the skin, mouth, stomach, intes- 
j tines, rectum, cervix uteri and bronchus. 
iThe resultant inflammation in the tumor 


has the same characteristics as infection 
elsewhere. 

Acute phlegmonous or suppurative infec- 
tions are but transient episodes in the 
history of any cancer; the majority of 
infections are subacute or chronic. A pre- 
dominance of polynuclear neutrophils, red 
blood cells, macrophages, eosinophils, and 
infant connective tissue cells indicates the 
acuteness of the infection ; the accumu- 
lation of small mononuclear cells, the 
abundance of fusiform cells and colla- 
genous fibers indicate a tendency to 
sclerosing proliferation. Sclerosis is pro- 
tective as well as inflammatory. The 
proteolytic digestion of enormous necrotic 
and suppurative cancer areas, contributes 
to the fever induced by the infection. 
Microbic infection may occur not only in 
the primary tumor, but may accompany 
the metastatic tumor deposits in the re- 
gional lymph glands. 

Erysipelas with diffuse and tubular 
lymphangitis occasionally attends cancers 
of the skin and mucous membrane. W. B. 
Coley observed spontaneous regression of 
a skin sarcoma following erysipelas infec- 
tion, and from this occurrence, conceived 
of the preparation of a bacterial toxin for 
the treatment of sarcomas (the well-known 
Coley’s toxin). I have observed the heal- 
ing of an ulcerative endothelioma of the 
parotid gland after the complication of 
facial wound erysipelas. 

Ulcerative cancers of the floor of the 
mouth are frequently followed by large 
adeno-phlegmons of the neck. A contrib- 
uting cause for this is the common 
extension of the sublingual glands through 
the muscles forming the floor of the mouth. 
Diffuse phlegmons of the pelvis minor are 
not uncommon in the presence of cancers 
of the rectum and prostate. 

The most dangerous cancerous fistulas 
are those which communicate the trachea 
and esophagus. The most frequent can- 
cerous fistulas are those which open be- 


182 


Pack — The Complications of Cancer 


tween the vagina and urinary bladder, or 
between the vagina and rectum, or in the 
male between the urethra and rectum. 

HEMORRHAGE. 

The blood vessels of the cancer, the same 
as those which supply normal tissue, are 
sensitive to vasomotor influences, so in cer- 
tain cases can become passively or actively 
congested. Under such circumstances an 
important hemorrhage can issue from an 
insignificant vascular lesion. In sarcomas 
and large carcinomas of the kidney, testi- 
cle, and ovary, infactions frequently re- 
sult in extensive interstitial hemorrhages. 
The friability of tumor tissue, the mechan- 
ics of slight traumas, the changes in tem- 
perature and inflammatory congestion and 
necrosis by bacterial action, are the con- 
tributing causes to hemorrhage. 

Infection provokes the development of a 
richly vascular granulation tissue. As a 
rule the hemorrhage occurs from the tumor 
proper and not by contact with the tissues 
which it invades. The separation of large 
sloughs, produced by necrosis and infec- 
tion, often causes violent hemorrhage, 
when the necrosis is too rapid to permit 
the included blood vessels to become pro- 
tectively closed against hemorrhage by 
obliterative endarteritis. 

Oftentimes it is a sudden and unexpected 
large hemorrhage, which reveals to the 
patient the existence of a cancer of the 
stomach or of the uterus. The direct hem- 
orrhage from cancers of the tongue, the 
blood in the vagina from uterine cancer, 
the melena in cancer of the rectum, and 
hematemesis in cancer of the stomach are 
of diagnostic and prognostic significance. 
One occasionally sees in a cancer of the 
cervix, an arteriole of large calibre, giving 
rhythmic jets of blood, so as to necessitate 
ligation. Rupture of a great vessel as 
jugular vein or lingual artery, may result 
from cancerous infiltration of its wall and 
lead to profuse hemorrhage and death. 


THE SPECIFIC VISCERAL COMPLICATIONS OF CANCER. 

THE BLOOD. 

Researchers have sought for a definite, 
unique hematologic form of cell or plasma 
constituent, which would give a specific 
sign of cancer, or serve as a prognostic 
evaluator, but these efforts have been 
futile. In addition to hemorrhage, most 
authors concede a direct influence of the 
cancerous process on the hematopoietic 
system. They have said that the habitual 
cancer anemia is established as the result 
of a sort of equilibrium between the hema- 
toxic and myelotoxic action of the cancer, 
on the one hand, and hematopoiesis on the 
other. The hematologic syndromes are 
those of either a simple or a pernicious 
anemia, i. e., orthoplastic or dysplastic. 

When anemia appears in the cancerous 
person, it is usually a simple, secondary 
form. The red blood cells have their nor- 
mal form; their response to hypotonic 
fragility tests is normal. The sedimenta- 
tion time is normal. The coagulation time 
and bleeding time are normal, therefore 
the accidental profuse hemorrhages are 
strictly local phenomena and are not ex- 
pressions of a generalized blood dyscrasia. 

Nucleated red blood cells are .rarely 
found in the simple secondary anemias. 
If the red blood count is fairly high and 
yet normoblasts occur, it may suggest 
metastasis to the bone marrow. Such a 
condition is termed myelophthisiccanemia. 
Data from the Mayo Clinic indicate that 
anemia is quite common in cancers of the 
ascending colon and cecum, less so in those 
of the transverse colon and progressively 
less common as the rectum is approached. 

One is occasionally surprised to observe 
an erythrocyte count of 4,500,000 with 80 
per cent hemoglobin in a cancerous patient, 
who appears very pale and anemic. This 
pallor is different from the ochrodermia 
of chlorosis and the pallor of simple 
secondary anemia. 


Pack — The Complications of Cancer 


183 


In the very rare pernicious form of 
anemia in the cancerous patient, the hemo- 
globin percentage is below 50 per cent; 
there is an increased fragility of the ery- 
throcytes, a diminished coagulability of the 
blood and a progressive course. The bleed- 
ing time is as high as 25 minutes. Normo- 
blasts abound and poikilocytosis exists. 

There are no specific changes in the 
white blood counts in cancer; infection 
of the cancerous area elicits the usual 
response. 

THE DIGESTIVE TUBE. 

Of all the accidents which accompany 
the development of malignancies of the 
digestive tube, the mechanical troubles are 
the most common. In the early siege of 
cancer of esophagus, pylorus or intestine, 
it is some interference with passage of the 
bolus, which often reveals the tumor. 

Cancer of the pharynx and esophagus do 
not cause stomach troubles if the patient 
can be made to eat. The appearance of 
the signs and symptoms of gastro-intes- 
tinal dysfunction indicates always that the 
patient has entered into the period of com- 
plications. In fact, during the course of 
evolution of gastric cancer, the digestive 
symptoms are usually slight and are 
ignored. 

The complications of gastric cancer are 
stenosis, anemia, cachexia, hemorrhage, 
uremia and hepatic insufficiency due to in- 
direct action on the kidneys and liver. The 
gastric functions remain excellent for a 
long time in patients having cancer of the 
rectum or large intestine. 

Carcinoma of the esophagus is some- 
times complicated by lung abscess. Papil- 
lary, pedunculated and polypoid tumors of 
the small intestine occasionally become in- 
corporated in intussusceptions because of 
peristaltic traction on the exposed body of 
the tumor. 

THE LIVER. 

Metastasis into the center of the liver is 
^^ten silent and is discovered only at 


necropsy. Cancers of the ampulla of 
Vater, of the head of the pancreas, of the 
gall-bladder and of the stomach with 
malignant lymphadenopathies, produce 
alarming symptoms which attract the at- 
tention of the patient. Even incomplete 
obstruction of the bile ducts will occasion 
dilatation of the biliary canals, bile stasis, 
augmentation in liver volume, icterus, sup- 
pressions of biliary function and digestive 
disturbances. 

Courvoisier’s law owns many exceptions, 
but it is generally true: In jaundice due 
to pressure on the common bile duct from 
without, as from cancer of the head of the 
pancreas, the gall-bladder is distended, 
whereas in jaundice due to impaction of a 
stone in the common duct the gall-bladder 
is usually contracted. The icterus of can- 
cer is further distinguished from the 
icterus of lithiasis by the fact that the 
former is followed usually by fever and 
disorders of hepatic insufficiency. It is 
very important to realize that infection of 
the biliary passages is the rule, in those 
cases where obstruction is caused by a 
neoplasm. 

Oftentimes the icterus is the only symp- 
tom or the only clinical expression of the 
disease, and the cause of it may be prob- 
lematical, requiring roentgenological ex- 
plorations, fecal examinations and re- 
searches into pancreatic insufficiency. This 
icterus is a grave, mortal condition. 

THE PERITONEUM. 

The most banal of all peritoneal re- 
sponses to adjacent cancers is a localized 
inflammation or peritonitis in the neigh- 
borhood of the neoplasm, which causes 
adhesions and enclosed spaces containing 
serous exudate. A plastic inflammatory 
reaction always accompanies cancerous in- 
filtration of the peritoneum. Cancers of 
the rectum, prostate, uterus, intestine, 
kidney and pylorus produce this type of 
peritoneal condition. 

It is remarkable that most of the cancers 
of the rectum, uterus, sigmoid colon, cecum 


184 


Pack — The Complications of Cancer 


and urinary bladder do not provoke ascites 
frequently, whereas it is very common 
after metastases from stomach and testis. 
The ascites of cancer is never comparable 
in volume with that accompanying portal 
cirrhosis of the liver. The ascitic fluid is 
a lemon yellow, clear, slightly fibrinous, 
occasionally hemorrhagic exudate, which 
may show the cell-groups of Foulis, on 
microscopical examination of the centrif- 
uged sediment. 

Chylous or milky non-inflammatory as- 
cites may follow occlusion of the thoracic 
duct. 

The classic type of fulminating gen- 
eral peritonitis is exceptional in cancerous 
individuals. It occurs as a terminal in- 
fection, in consequence of a precocious 
perforation of a cancer or of an intestinal 
obstruction, especially of the large intes- 
tine. However, malignant ulcers of the 
gastro-intestinal tract seldom perforate. 
The suppurative peritonitides accompany- 
ing secondary peritoneal cancers, are 
always localized, blockaded pockets of pus; 
for example, one seldom observes sub- 
diaphragmatic abscess complicating ab- 
dominal cancer. 

THE LUNG. 

The tolerance of the pulmonary pa- 
renchyma to the development of neoplas- 
tic growths is remarkable. Tuberculous 
infection of a comparative degree causes 
considerable anatomical and functional 
disorders, but the more important neo- 
plasms propagate in silence. The evolution 
of pleuro-pulmonary cancers is usually 
insiduous. Dyspnea and expectoration do 
not appear in the majority of cases until 
after bronchial ulceration occurs. 

Obstruction of a bronchus by an invad- 
ing cancer causes atelectasis of the adja- 
cent lung, accumulation of secretion within 
the bronchioles and the development of 
broncho-pneumonic foci. Broncho - pneu- 
monia is also a terminal infection, fre- 
quently occurring by aspiration in cancers 
of the mouth, pharynx and larynx. 


The invasion of the pleura by cancer 
often produces no inflammatory reactions. 
The pleura is not as sensitive to neoplastic 
infiltration as is the peritoneum. Some- 
times a clear, greenish-yellow, fibrin-poor, 
pleural effusion will appear, but possibly 
a concomitant infection is necessary to in- 
duce this transudation. The presence of 
a sanguinous liquid in the pleural sac, 
which is insisted upon by some authors, is 
the exceptional rather than the usual 
finding. Such a fluid indicates a special 
kind of pleuritis, or possibly the degenera- 
tion of a pleural tumor, such as the vege- 
tating endothelioma of the pleura. 

Pulmonary gangrene and pleural em- 
pyema are very rare complications. Cancer 
of the pharynx may cause stertorous 
breathing or snoring. Cancer of the 
larynx may cause stridulous breathing or 
stridor. Cancer of the trachea or pres- 
sure against the trachea by extra-tracheal 
tumors may obstruct it to produce the 
peculiar leopard growl. 

THE MEDIASTINUM. 

The disturbances produced by medias- 
tinal tumors are variable and depend on 
the tissues compressed and the location of 
the enlargements. The symptoms are 
directly due to irritation and compression 
of such structures as nerves, bronchi, heart 
and blood vessels. The two functions most 
interfered with are respiration and 
circulation. 

Dyspnea is the first and often the only 
sign of mediastinal neoplasm; the follow- 
ing types occur — effort dyspnea, dolorous 
dyspnea and dyspnea in the form of noc- 
turnal asthma. The cardiac difficulties are 
due to displacement of the heart resulting 
in tachycardia, ar^rthmias and the syn- 
drdmo of myocardial asthenia. 

Stoke’s sign is an edema and cyanosis 
of the neck, face and upper extremities 
following partial obstruction to venous re- 
turn through the superior vena cava. 
Death may be due to broncho-pneumonia, 


Pack — The CempUeations of Cancer 


185 


embolism, myocardial failure or cardiac 
thrombosis. 

Dysphagia from esophageal obstruction 
is uncommon. Involvement of a phrenic 
nerve has resulted in persistent hiccough. 
Malignant tumors of the upper medias- 
tinum may press against or irritate or 
destroy the recurrent laryngeal nerves, 
causing the brassy or “goose” cough, or 
may result in the asphyxia of bilateral 
abductor paralysis. 

THE CARDIO-VASCULAR SYSTEM. 

The capillaries of the host are inti- 
mately associated with the parasitic cancer. 
Sarcomas and some epitheliomas may per- 
forate into the lumen of the vessel to form 
vegetating masses, which frequently are 
the source of emboli. Some of the blood 
vessels of the cancer are converted into 
hyaline cords by a sclerosing inflammation 
in their walls. Inflammation is more de- 
structive of large blood vessels, than is the 
neoplastic process. Obliteration of the 
nutritive vessels in the pedicle of a pedunc- 
ulated tumor results in immediate necrosis. 

Lymphedema of an upper extremity, 
either subsequent or unrelated to axillary 
dissection for cancer is of unknown cause. 
Handley states that interference with 
lymphatic drainage following removal of 
the axillary lymph nodes is insufficient 
cause. Although the clinical aspect of the 
condition is that of a thrombosis, necropsy 
reveals that all the large veins from the 
arm are permeable. Infection or cancerous 
infiltration may induce cicatrical contrac- 
tion which exerts external pressure on 
these large veins resulting in this peculiar 
condition. 

Phlebitis-phlegmasia alba dolens occurs 
in some vessels as a complication of an in- 
fected cancer. A rather sudden and deep 
pain followed by edema is the usual course 
of events. After an interval of three to 
four months, the edema is resorbed and 
the arm or leg regains its former function. 
As in other types of phlebitis, embolism is 
always a possible danger. Massive gan- 


grene may follow embolism in an artery 
of an extremity. 

The endocarditis of cancer is a local ex- 
pression of a diffusion of an infectious 
process. From a practical point of view, 
this is certainly one of the more important 
systemic complications of cancer. The en- 
docarditis of cancer is not frequently 
recognized by cardiologist or cancerologist, 
who incorrectly consider it as a terminal 
or coincidental infection. Endocarditis de- 
velops frequently in patients having greatly 
ulcerated cancers of the rectum, uterus or 
face. The primary endocardial lesion is an 
ulcer upon which a thrombus develops 
secondarily. It is a subacute affair and 
resembles the endocarditis lenta produced 
by the streptococcus viridans. From this 
thrombotic lesions, secondary embolic foci 
occur in liver, kidney, etc., but produce 
only subacute lesions. 

THE KIDNEYS. 

At necropsies performed upon individu- 
als who died of cancer, definite evidence of 
more or less important renal lesions are 
discovered but clinical examinations upon 
many of these same patients find incon- 
stant renal dysfunction. Of course, cancer 
can occur in a person who has had chronic 
nephritis for years. Nor is the nephritis 
occurring in a cancerous patient, neces- 
sarily dependent on the neoplasm. 

The rather common toxic-infectious 
nephritis is a true complication and part 
of the secondary infectious syndrome 
which follows ulceration and infection of 
the cancer. It sometimes occurs concom- 
itantly with the subacute thrombotic endo- 
carditis, previously mentioned. The glo- 
meruli are dilated and engorged with blood 
and the capsule is distended with sero- 
fibrinous exudate. Between the tubules 
and in the interstitial spaces are found 
accumulations of mononuclear and polynu- 
clear cells. There is a relative obliguria — 
400-800 cc. and never a hematuria. Renal 
tests inform one about this condition far 
sooner than physical examination does. 


186 


Pack — The Complications of Cancer 


The knowledge of this nephritis is of con- 
siderable prognostic importance. 

Death from kidney disease is the rule 
four times out of five in cancer of the 
uterus. With a few exceptions, this is the 
usual method of termination for persons 
having cancer of the bladder or prostate. 
Renal insufficiency is a frequent cause of 
death in cases of rectal cancer. 

Urinalysis demonstrates that nephritis 
always precedes cachexia and indeed may 
be the chief cause of it. One must discard 
the opinion that cachexia results from the 
absorption of products from tumor tissue, 
because of the absence of signs and symp- 
toms of toxemia following acute regression 
of enormous myelogenous spleens and 
mediastinal lymphosarcomas after roent- 
gentherapy. 

Compressions of the ureter or ureters is 
not only caused by enormous neoplasms 
which transform the pelvis into a cancer 
en bloc (frozen pelvis), but also by small 
tumors so placed as to obstruct the ureter 
(uretero-cystic orifice). Sometimes this 
constitutes the first sign of parametrial in- 
vasion of uterine cancer. The conse- 
quences are well known, viz., hydronephro- 
sis, pyelitis and uremia. The distention of 
the kidney pelvis is slowly progressive, due 
to the persistent function of the glomeruli. 
The hydro-nephrosis may occur in a kidney 
that is already the seat of a toxic-infec- 
tious nephritis. If cystitis is present, the 
hydronephrosis may be transformed into 
a pyelonephritis, which in turn occasionally 
leads to a perirenal abscess. 

SUMMARY. 

Most cancerous individuals die from 
complications rather than from the natu- 
ral progress of the disease. 

By the time a cancer has caused stenosis 
of a visceral lumen sufficient to evake 
symptoms, it is very late in its course. 

Ulceration and hemorrhage are critical 
local events in the history of ay cancer. 


Infection usually hastens growth of the 
cancer and handicaps therapeutic meas- 
ures. 

Polypoid tumors of the small intestine 
occasionally become incorporated in intus- 
susceptions. 

The complications of gastric cancer are 
stenosis, anemia, cachexia, hemorrhage, 
uremia and hepatic insufficiency. 

The hematologic syndromes of cancer 
are those of either a frequent secondary 
anemia or a very infrequent pernicious 
anemia. If the red blood count is fairly 
high and yet normoblasts occur in some 
abundance, it may suggest metastasis to 
the bone marrow. 

The obstructive icterus of cancer is dis- 
tinguished from the icterus of lithiasis by 
the flexible application of CourvoisieUs 
law and by the fact that the former jaun- 
dice is followed usually by fever and dis- 
orders of hepatic insufficiency due to re- 
sultant infection of the biliary passages. 

It is remarkable that most of the can- 
cers of the rectum, uterus, sigmoid colon, 
cecum and urinary bladder do not provoke 
ascites frequently, whereas it is very com- 
mon after metastases from stomach and 
testis. 

The pleura is not as sensitive to neoplas- 
tic infiltration as ns the peritoneum. 

Dyspnea is the first and often the only 
sign of mediastinal neoplasm, the follow- 
ing types occur — effort dyspnea, dolorous 
dyspnea and dyspnea in the form of noc- 
turnal asthma. 

Stoke’s sign is an edema and cyanosis of 
the neck, face and upper extremities fol- 
lowing partial obstruction to venous re- 
turn through the superior vena cava. It 
is frequently observed late in the history 
of a mediastinal tumor. 

Lymphedema of the arm following pri- 
mary or secondary auxilliary tumors, be- 
fore or after operation is due to infection 


LEMANN—Glandidar Fever With Report of Epidemic in Local Orphanage 


or cancerous infiltration with, cicatricial 
contraction, which exerts external press- 
ure on the large veins draining the limb. 

The endocarditis of cancer is frequent in 
patients having greatly ulcerated cancers 
of the rectum, uterus or face. It is sub- 
acute in course and resembles the endocar- 
ditis lenta produced by the streptococcus 
viridans. 

Toxic infections nephritis and obstruc- 
tive urinary lesions are very common com- 
plications of cancer. The majority of 
patients having cancer of the uterus, pros- 
tate or urinary bladder, and a large num- 
ber of those having rectal cancer die from 
secondary kidney disease. 


GLANDULAR FEVER WITH REPORT 
OF A SMALL EPIDEMIC IN A 
LOCAL ORPHANAGE.* 

I. I. LEMANN, M. D.,f 
New Orleans. 

Ten boys ranging in age from eleven to 
seventeen from Hope Haven, a local or- 
phanage located in the open country di- 
rectly across the river from New Orleans, 
were admitted to the wards of Touro In- 
firmary in the period from June 3 to July 
21, 1927. The total population of the or- 
phanage was only sixty-five. The com- 
plaints of the patients, the course of their 
disease, the findings on physical examina- 
tion and the results of laboratory investiga- 
tions were so closely parallel in all ten 
cases as to leave no doubt that we were 
dealing with an epidemic of some sort. 
The disease was very mild and none of the 
boys were very sick. About six of these 
patients I saw, the other four were seen by 
my colleagues Drs. C. L. Eshleman and J. 
C. Cole. 


*Read at the meeting of the Orleans Parish 
Medical Society, April 23, 1928. 

fFi’on'i the Medical Service of Touro Infirmary 
and the Department of Medicine, Tulane School of 
Medicine. 


The illness was characterised by a sud- 
den onset, usually with headache. One 
boy had a chill, two had abdominal pain, 
two vomited at the onset, one complained 
of burning eyes, none had sore throat. The 
fever rose usually to 103° or 104° and in 
one case as high as 106°. Even the last 
patient was not very ill at the height of 
his fever. The fever lasted four or five 
days and terminated by crisis. In only 
one case did the fever last more than five 
days; here it lasted eight days. Aside 
from the headache there was litle discom- 
fort — not even as much malaise as one or- 
dinarily expects with fever to these levels. 
There was not even the usual anorexia. 
As soon as the fever was gone the boys 
were eager to be up. 

All the boys were well nourished. The 
heart and the lungs were normal in all 
but one case ; here it is recorded that a 
loud systolic murmur was heard. Every 
boy except the first one admitted showed 
a definite enlargement of the lymph nodes. 
It is possible (and probable) that this first 
boy also had an adenopathy which was 
overlooked. In the other nine patients the 
cervical glands were enlarged in 4 cases, 
the submental in 1 case, the epitrochlears 
in 6 cases, the axillary in 1 case and the 
inguinal in 6 cases. The spleen was en- 
larged in 4 instances. The spleen was 
found enlarged in a fifth case where the 
boy was re-admitted a second time a month 
after his first admission. Reference will 
be made again to this later on. I noted 
in four cases a fine, discrete papular rash, 
like the rose colored spots of typhoid on the 
chest and abdomen. These spots would 
fade on pressure, promptly to return. In- 
deed the occurrence of this rash and the 
enlargement of the spleen at first aroused 
the suspicion of typhoid, particularly when 
it was evident that we were dealing with 
some epidemic disease. The course of the 
illness, however, soon made this diagnosis 
untenable. The blood cultures were all 
negative. The agglutination test of the 
blood with B. typhosus in dilutions of 1 to 


188 Lemann — Glandular F ever With Report of Epidemic in Local Orphanage 


60 were negative. The rash aroused too 
the suspicion of typhus (or Brill’s disease) 
and of dengue. As to the former, there 
was no prostration nor any clouding of the 
sensorium. As to the latter, there were 
lacking entirely the severe pain of “break 
bone” fever. The constant adenopathy 
could not be explained by any of these 
hypotheses. At the time no diagnosis 
was set and the histories were recorded as 
of “fever of unknown origin.” Recently 
I have again reviewed these histories and 
feel that we are justified in regarding this 
small epidemic as one of glandular fever. 


or identical conditions variously named.” 
Since their report, the Quarterly Cumula- 
tive Index shows fourteen articles listed 
under the title of glandular fever or infec- 
tious mononucleosis. Definite clear cut 
epidemics have been reported in England, 
on the continent and in this country. The 
largest of these was by Guthrie and Pes- 
sel< 2 ) in 1925. They observed an outbreak 
of three hundred cases in the student body 
of about five hundred boys ranging in age 
from thirteen to eighteen in the Lawrence- 
ville School, Lawrenceville, N. J. The 
next largest epidemic is that reported by 


TABLE I. 


Case 

Mode of 
Onset 

Termination 

Max. Temp. 

Pulse 

Spleen 

Lymph Nodes 
Enlarged 

Eruption 

1. 

Vomiting 

Fever 

Headache 

5 

da. crisis 

104.6° 

80-125 


None 1 

-f 

2. 

Vomiting 

Headache 

Fever 

4 

da. crisis 

105° 

80-110 

+ 

Epitrochlear 

Inguinal 


3. 

Headache 

Fever 

2 

da. crisis 

103° 

100-105 

? 

Submaxillary 

Axillary 


4. 

Headache 
Pains in 
abdomen 

5 

da. crisis 

102.6° 

80-122 


Epitrochlear 

Inguinal 

-h 

5. 

Burning 
of Eyes 

8 

da. crisis 

104° 

86-118 

+ 

Epitrochlear 

Inguinal 


6. 

Headache 

Fever 

4 

da. crisis 

104.4° 

80-115 


Cervical 


7. 

Headache 

3 

da. crisis 

102.6° 

80-112 


Cervical 

Inguinal 

-h 

8. 

Fever 

5 

da. crisis 

102.6° 

95-100 

+ 

Epitrochlear 

Inguinal 



9. 

Chill 

5 

da. crisis 

104.2° 

100-120 


Inguinal 

-1- 

10. 

Headache 
Pains in 
abdomen 

3 

da. crisis 

103.4° 

90-110 


Epitrochlear j 
Cervical 


11. 

Headache 

Fever 

8 

da. crisis 

100.2° 

80 

_ 

Inguinal 

Cervical 


12. 

Spells of 
■weakness 
for 8 Mos. 

Irregular 

Curve 

104° j 

1 

80-125 1 

+ 

Inguinal | 

Cervical | 

-t- 


Although it is now forty years since 
Filatow in 1885 and E. Pfeiffer in 1889 
first described a fever characterised by an 
adenopathy, practically no progress has 
been made in establishing this as a dis- 
tinct clinical entity. Baldridge, Rhoner 
and Hansmann<i> in 1926 report: “There 
have been more than one hundred and ten 
articles published on glandular fever and 
about half as many articles on similar 


J. Park West<®\ 96 cases in a small town 
in Eastern Ohio. Baldridge, Rhoner and 
Hansmann<i) saw 32 cases in the first six 
months of 1925 at Iowa City, Iowa. Be- 
sides the definite epidemics varying in 
size, many sporadic cases have been re- 
ported; thus Baldridge and his associates 
had seen 18 cases scattered from 1914 to 
1924 and Longcope^^) in New York had 
observed 10 cases from 1909 to 1922. 


Lemann Glandtdar Fever With Report of Epidemic in Local Orphanage 


ETIOLOGY 

In spite of well planned investigations 
such as cultures from the throat, blood, 
and extirpated glands, hematological stu- 
dies and histological studies of extirpated 
glands, no one has been able to discover 
the cause of the disease. Streptococci, 
staphylococci, organisms of Vincent’s an- 
gina, diphtheroid organisms have at times 
been found and suggested as the etiologi- 
cal factor but no definite basis for the as- 
sumption of any of these has been adequate 
ly established. Our knowledge of the dis- 
ease is practically entirely clinical since 
there is no mortality. A few deaths have 
been reported but in none of these is it 
well established that the case by right be- 
longs in the group which we are now dis- 
cussing. 

EPIDEMIOLOGY 

I have already indicated the wide dis- 
tribution of the disease. The present 
epidemic is as far as I know the first to be 
reported from this stection. Dr. Chaille 
Jamison^®) read a paper in 1923 before 
the Louisiana State Medical Society on 
glandular fever but he made no reference 
to cases seen by him. Evidently children 
and young adults are more susceptible 
than older people. The definite epidemics 
have broken out practically entirely among 
children and adolescents. Byers’ 33 
cases ranged in age from thirteen months 
to twenty-five years. Longcope’s 10 cases 
(non-epidemic) ranged in age from twelve 
to thirty. In the series of Baldridge, 
Rhomer and Hansmann, the youngest was 
six and a half years and the oldest forty. 
The incubation period is said to be be- 
tween five and nine days. 

SEASONAL DISTRIBUTION. 

The time covered by the epidemic re- 
ported by Guthrie and PesseB^^ was from 
the latter part of September to the third 
week in November, 1922. In J. Park 
West’s^®' series, 1 case occurred in Sep- 
tember, 1 in October, 13 in March, 12 in 
February, 12 in November, 11 in January, 
10 in May, 8 in December and 6 in April, 


1896. No cases occurred in June, July 
and August. Baldridge, Rhoner and 
Hansmann^^^ report that their epidemic 
began in December, reached its height in 
March and extended through the first six 
months of 1925. It will be noted that the 
present epidemic occurred in the summer, 
at the very time when West had no cases. 
It would appear that the disease may oc- 
cur at any time of the year. 

SYMPTOMATOLOGY 

In addition to the enlargement of the 
glands and the fever, the following have 
been noted in a large percentage of the 
cases : general malaise, headache, chills, 
sore throat, enlarged tonsils, enlarged 
spleen, enlarged liver. In some cases ad- 
dominal pain and tenderness have been 
noted. Longcope observed a macular 
eruption of small, dull red spots in some of 
his cases. Baldridge and his associates 
have compiled a long list of various symp- 
toms and physicial observations, some of 
which perhaps stood in no special relation 
to the specific disease. Guthrie aind Pessel 
believe that although one hundred and 
twelve boys were actually admitted to the 
infirmary, a very much larger number ac- 
tually had the disease in so mild a form 
that they were treated as ambulatory pati- 
ents. Because at a subsequent physical 
examination of all the boys in the school 
a surprisingly high incidence of marked 
general glandular enlargement was found, 
they believed that there has been over 
three hundred cases in the school. Others 
have also referred to the exceedingly mild 
character of the attacks in other epidemics. 
This corresponds to our experience here 
for we believe that the ten patients whom 
we received in Touro Infirmary by no 
means represent the total incidence at 
Hope Haven. Dr. D. D. Warren, who went 
out to inspect Hope Haven and to look at 
the other boys during the time we were re- 
ceiving sick ones at Touro, tells me that 
other boys, probably as many as fifteen, 
were sick at this time but in so mild a 
fashion, that it was not considered neces- 


190 Lemann — Glandular F ever With Report of Epidemic in Local Orphanage 


sary to send them in to the hospital. Dr. 
Warren and I recently inspected fifty- 
seven of the boys at Hope Haven (April 
6, 1928) nine months after the epidemic 
and found in all very definite enlargement 
of the lymph nodes. The nodes varied in 
size from that of a pea to that of the distal 
phalanx of an adult thumb. Many of the 
boys had a general adenopathy, the cer- 
vical, epitrochlear and inguinal glands be- 
ing involved; others exhibited enlarge- 
ment of ony one group. Practically all of 
them had inguinal gland enlargement. 
Although the epidemic is usually repre- 
sented "by a febrile attack of from two to 
five days, there have been cases in which 
the glands re-enlarge and become tender 
at variable periods after the initial attack. 
“Such recurrences are often associated 
with some fever and many of the symp- 
toms of the original infection. We have 
followed one patient through four such 
attacks in the last three years. The spleen 
is usually enlarged only a few days but we 
have one patient in whom the spleen was 
much enlarged at the onset and has re- 
mained palpable for seven years without 
known cause.” Two of our patients 
from Hope Haven were re-admitted a few 
weeks after their first admission. E. J., 
was admitted June 13, 1927, on the first 
day of his illness and had a crisis on the 
fourth day, his temperature having risen 
to 105°. His spleen was palpable and he 
had enlarged epitrochlear and inguinal 
glands. The tonsils were greatly en- 
larged. He was re-admitted September 
2, with the story that he had felt perfectly 
well until that morning when he awoke 
with a severe frontal headache. His ton- 
sils had been removed six weeks before, 
that is to say July 23, 1927. On this sec- 
ond admission the temperature rose to 
103° and fell by crisis after two days. The 
spleen was palpable. The submental and 
axillary glands were enlarged. 

C. 0. was admitted July 29, 1927 with 
headache, fever and abdominal pain. The 
illness had begun one week before with 


headache and fever. In the hospital his 
temperature did not rise over 100.2° and 
fell to normal the day after his admission. 
His cervical and inguinal glands were en- 
larged. The spleen was not palpable. His 
tonsils had been removed three weeks pre- 
viously. He was re-admitted on August 
29, 1927, with a fever of 100° which ran an 
irregular course, rising as high as 104.2° 
on September 2, 1927. His spleen was large 
and hard. He had marked enlargement of 
the cervical and inguinal glands. On 
September 5 when his temperature was 
100.8°, having previously fallen to normal, 
quinine was begun and he received seventy 
grains from 8 P. M. September 5 to 8 P. 
M. September 8. The termperature did 
not rise until September 10. From the 
eleventh to the thirteenth it rose to 99.4°. 
There is, of course, a question as to 
whether the quinine caused a decline of the 
temperature. No plasmodia had been 
found in the blood. 

HEMATOLOGY 

Guthrie and PesseP^^ found early in the 
disease a moderate polymorphonuclear 
leukoc 3 rtosis and later counts showed in 
many instances normal or slightly sub- 
normal total count with an increase in the 
lymphocytes. Baldridge antj his asso- 
ciates (d found a total leukocyte count usu- 
ally above normal at the onset and below 
normal in the convalescence: "A poly- 
morphonuclear leukoc}d;osis may occur at 
the onset, especially in cases with marked 
febrile reactions. Sometime during the 
course the blood shows a rather marked in- 
crease in mononuclear cells.” Longcope<'‘> 
found during the first week of the dis- 
ease ; An absolute and relative increase 
in the mononuclear cells of the blood with a 
slight but distinct decrease in the total 
number of granular cells. Total leukocyte 
count at the onset from 9,800 to 26,200. 
This high leukoc 3 rte count lasted only a few 
days. There was a steady increase in the 
non-granular mononuclear cells definitely 
from the seventh day, reaching its height 
usually about the tenth or fourteenth day. 


Lem ANN — Glandular Fever With Report of Epidemic in Local Orphanage 191 


Following this there with a decrease in the 
total leukocyte count was a gradual reduc- 
tion in the mononuclear cells”. Many ob- 
servers have called attention to the abnor- 
mal character of the mononuclear cells oc- 
curring sometime during the course of the 
disease. Guthrie, however, comments that 
“In no instance was a blood picture en- 
countered that was nearly so striking, par- 
ticularly in regard to the increase of im- 
mature lymphocytic cells, as that presented 
in the case we have seen of “infectious 
mononucleosis” in young adults. It is en- 
tirely probable that such conditions were 
present but escaped recognition as we did 
not make daily examinations of the blood 
over a long period in any of the patients.” 
This unfortunately was also the case with 
us. An average of only one blood count 
was made on each patient in our series. 
Reference to the accompanying table will 
show that most of the patients had normal 
or subnormal leuckoyte counts. There are 
three counts of 4,000 or less and only four 
above 6,000. The highest was 12,000. This 
variation may have been due to the fact that 

TABLE n. 


BLOOD PICTURE 


Case 

Leukocytes 

Neutro- 
phils 
Per Cent 

Small 
Mononu- 
clears 
Per Cent 

Day 

. 1 

3,500 

60 

33 

3 

2 . 

8,000 

60 

27 

2 

3 . 





4 . 

6,500 

59 

26 

5 

5 . 

12,000 

85 

13 

5 

6 . 

5,000 

44 

52 

4 

7 . 

8,600 

60 

40 

3 

8 . 

4,000 

26 

54 

6 

9 . 

5,500 

70 

28 

3 

10 . 

9,500 

74 

20 

1 

11 . 

8,000 

50 

46 

9 

12 . 

5,100 

55 

43 

4 


some of the counts were made early 
in the attack, others relatively later. I 
have indicated on the chart the day on 
which the counts were made. It will be 
noted that a few of them showed abnorm- 
ally large percentage of mononuclear cells. 
No detailed study was made of these cells. 

RELATION OF GLANDULAR FEVER TO INFECTIOUS 
MONONUCLEOSIS 

Guthrie says: “If as has been suggested, 
infectious mononucleosis represents mere- 
ly the picture produced by sporadic inci- 
dences of glandular fever in young adults, 
it may be that the effect on the blood is ac- 
tually somewhat different from that pro- 
duced by milder attacks occurring in epi- 
demic form among young people.” Bald- 
ridge and his associates also comment on 
“the fact that the percentage of mononu- 
clear cells averages much higher in sporadic 
cases than in epidemic cases.” I, too, have 
the same impression. Recently, there came 
under my observation a young man, aged 
25, a resident of New York who while on a 
visit to relatives here developed at the end 
of last December an irregular fever which 
lasted more than a month. At no time was 
he very sick. He had no complaint except 
occipital headache and a general malaise 
when the fever was present. The physical 
examination revealed nothing beyond a 
slight pharyngitis and an enlargement of 
the cervical glands. One at the angle of 
the jaw was still the size of a small marble 
and tender one month after the onset. The 
left submental gland was also still palpable 
and tender. Tke spleen was never en- 
larged, though repeatedly searched for. 
The blood pictures were, as follows: red 
blood cells 6,170,000 ; white blood cells 
8,100; polymorphonuclears 63; large mono- 
nuclears 6 2/3; small mononuclears 25; 
eosinophils 5; and 'basophils 1/3 per cent. 

1- 25-28 — Red blood cells 5,345,000 ; white 
blood cells 8,250; polymorphonuclears 20; 
large mononuclears 5; small mononuclears 
63 and eosinophils 2 per cent. 

2- 11-28 — Red blood cells 5,580,000; white 
blood cells 8,100 ; polymorphonuclears 


192 Lemann — Glandular Fever With Report of Epidemic in Local Orphanage 

* 


57 1/3 ; large mononuclears 4 ; small mono- 
nuclears 36 and eosinophils 3 2/3 per cent. 

I am inclined to look upon this as a spor- 
adic case and call attention to the tran- 
sient mononuclosis. If there is really a dif- 
ference such as indicated by Guthrie and 
Baldridge and now by myself, one may ask 
whether actually the epidemic and the spor- 
adic cases are examples of the same disease. 
I am also impressed by the constant refer- 
ence by reporters to the occurrence of sore 
throat and even of membranous angina. 
In view of the leukopenia and the mononu- 
cleosis, I am led to ask what is the relation 
between such cases and agranulocytic an- 
gina and what the points of differential 
diagnosis between the two? True, agran- 
ulocytic angina is nearly always fatal, 
glandular fever (infectious mononucleosis) 
never fatal. I have recently, however, 
seen an old woman, age 70, recover from 
agranulocytic angina. In both conditions 
the etiological factor is unknown. Both 
represent unusual and abnormal reactions 
of the recitulo-endothelial system to infec- 
tions. Is the difference of this reaction 
merely one of degree or intensity? In this 
connection, too, there comes to mind the 
mononucleosis which has been noted in 
various conditions not apparently related 
to epidemic glandular fever or even to the 
sporadic glandular cases. These would 
seem to represent abnormal reticulo-endo- 
thelial reaction to varying invading organ- 
isms and not to represent a true distinct 
entity. Such a case was that of a young 
man, aged 21, who after a carbuncle of the 
back developed a septicemia which in turn 
was followed in his convalescence by an 
enlargement of the spleen and a mononu- 
cleosis. At the time of his carbuncle and 
even in his convalescence he is reported to 
have had a leukocyte count of 13,000 with 
82 per cent of polymorphonuclears. Fol- 
lowing this he had a little redness and 
slight edema of his throat. A little later 
his spleen was found enlarged to two 
fingers below the costal margin. Then 
the leukocyte count was 11,600 with 81 per 


cent of (very) large mononuclears, 4i/^ per 
cent of small mononuclears, 13 per cent of 
polymorphonuclears and 1 per cent of eosi- 
nophiles. The count in two weeks shifted 
to 11,200 leukocytes, 68 per cent of small 
lymphocytes, 5 1/3 per cent of large lym- 
phocytes, 22 2/3 per cent of polymorphonu- 
clears and 4 per cent of eosinouhils. Grad- 
ually the lymphocytosis diminished and 
with this there was a surprising eosino- 
philia to as high as 11 per cent. This eosi- 
nophilia in turn gradually disappeared. 
After two months the blood 'picture was 
almost normal and two months later it was 
quite normal. 

SUMMARY 

Report is made of a small epidemic of 
glandular fever. Ten cases were observed 
but there were probably twenty-five or 
thirty boys ill out of a total boy population 
of sixty-five. The relation is discussed of 
epidemic glandular fever to sporadic cases 
with glandular enlargement and mononu- 
cleosis, to agranulocytic angina and to 
mononucleosis occurring in varying infec- 
tions. 

REFERENCES 

Baldridge, Rhoner and Hansmann: Arch. Int. Med., 
38:413, 1926. 

Guthrie, C. C. and Pessel, J. F. : Am. Jour. Dis. Child., 

29:492, 1925. 

West, J. Park: Arch. Pediat, 13:889, 1896. 

Longcope, W. T. : Am. Jour. Med. Sc., 164-781, 1922. 

Jamison, S. Chaille: N. O. Med. & Surg. Jour., 75:346, 

1923. 

Byers, J. W.; Lancet, 1:84, 1904. 

DISCUSSION 

Dr. D. D. Warren (New Orleans); There is 
no doubt in my mind but that this was a real 
epidemic. I was associated with this institution 
when the epidemic broke out. In going over every 
boy who came in we would make an examination 
of the glands and heart. So many had a small 
amount of fever and adenopathy that I tried to 
admit them into the Hospital, but soon realized I 
would be unable to do so. I therefore opened a 
room out at Hope Haven, isolated it and put the 
remainder of the boys there. When I told Dr. 
Lemann that the number taken care of over there 
was fifteen, I was being conservative. I really 
believe that a great many more than one-half of 
these boys came down with this glandular fever. 
I am not going to call it infectious mononuclesosis. 


Lemann — Glandular Fever With Report of Epidemic in Local Orphanage 193 


In looking np glandular fever I find “glandular 
fever or infectious mononucleosis.” Something 
is wrong somewhere. In the glandular fever 
epidemic reports of Gutherie, Longcope, and 
others their epidemics did not show the typical 
blood picture of infectious mononucleosis. If 
this is the same disease, glandular fever is the 
better term. 

It is interesting to note that while these boys 
were sick, none of the attendants came down vdth 
it. As I remember there were about ten atten- 
dants. 

Also, at the beginning of the epidemic, it just 
happened that every boy who was taken sick was 
working in the dairy. I at once thought of the 
possibility that it was some disease carried by 
cows and notified the State Board of Health. 
We did not get any definite report as to what 
they found. I believe they thought it was cow 
pox, due to two infected cows which they found. 

I wish I had had the opportunity to examine 
these boys before this epidemic. We know 
nothing of the adenopathy they showed before 
then. I know, as a rule, you do find the lymph 
nodes enlarged. This was different. These 
boys did not have little palpable nodes. It was 
not unusual to find an epitrochlear node as large 
as the end of the middle finger; inguinal nodes 
larger than the end of the thumb; there was real 
adenopathy. 

It is also interesting to note that the first 
case, the only case that showed any gastro-in- 
testinal symptoms, came on suddenly while the 
boy was driving the cows to pasture. It began 
with pain in the abdomen; he was brought im- 
mediately into Touro. He ran the same course 
as the others. 

A Wassermann was made in every one of these 
cases. As to the heart case Dr. Lemann men- 
tioned: I found no heart lesions in any of these 

boys as they were admitted. 

I have under observation now another group 
of boys at the Waif’s Home, of the same age as 
the boys at Hope Haven. While I do not wish 
these boys any harm, if they have an epidemic, 
I will study the disease more thoroughly. 

Dr. L. R. DeBuys (New Orleans) : We should 

all feel indebted to Dr. Leman for his interest- 
ing and thorough survey of the epidemic that he 
has just reported. The term glandular fever is 
used synonymously with infectious mononu- 
cleosis, also vdth acute infectious adenitis. The 
pathology of the disease is not definitely known 
because few of the cases require excision of the 
gland. In those cases, however, in which the 
gland does go to suppuration the ordinary pyo- 


genic organisms are found. The epidemics of 
glandular fever are usually found coincidentally 
vdth other epidemics, as for example, influenza. 

In the younger individuals tjie severer in- 
volvements of the glands are found. The only 
cases that I have seen where suppuration has oc- 
curred have been in these younger indidduals. 
In Pfeiffer’s original description the cases were 
mostly those of infants. The literature, how- 
ever, also contains epidemic in young adults. In 
those cases that go to suppuration no particular 
specific offending organism has been found. An 
interesting observation in connection with this 
disease is that the involvement of the gland is 
out of all proportion to the amount of infection in 
the area which these glands are supposed to 
filter. The glands most frequently involved are 
those of the neck. 

The atrium of infection is believed to be the 
nasopharynx. It is also believed that perhaps the 
tonsils are the point of entrance for the infec- 
tion. Dr. Lemann in his series has reported a 
patient in whom the tonsils had already been re- 
moved. I have also noted such instances, and 
one case in a child of 7 years had one of the most 
marked attacks which occured after the tonsils 
had been removed. 

The blood pictures in this series are interest- 
ing. Usually the blood picture described in 
acute glandular fever shows not only a lympho- 
cytosis but a leukocytosis. Undoubtedly this di- 
sease offers a field for future investigation. 

In closing I want to make one statement with 
regard to the treatment. In those cases where 
the gland tends to persist in size or tends to 
increase rather than to diminish in size nothing 
will give more spectacular relief than the use of 
the roentgen-ray. I want to emphasize the de- 
leterious effect of the large dosage of the roent- 
gen-ray. In a series of 10 cases, 3 cases were 
treated by one radiologist with large doses and, 
2 of these 3 went to suppuration, and the third 
had a prolonged convalescence. The dose given 
was from two-thirds to 1 skin unit. In the 
other 7 cases one of them went to suppuration. 
They received one-third of an erythema dose, 
and most of them had only one treatment. One- 
third of a erythema dose is therefore quite suf- 
ficient and most satisfactory and if it should be 
necessary to repeat the dose it may be done with 
further improvement. 

Dr. E. D. Fenner (New Orleans) : I would 

like to ask one question — ^whether these glands 
were tender or painful, or not? 

Inasmuch as the symptoms do not seem to be 
very definite, the blood picture is not actually 


194 


Smith — Jaundice Occur'7'ing in Untreated Syphilis 


characteristic, the disease is mild and self- 
limited, and as children are likely to have en- 
larged glands, I hope we will not have a univer- 
sal outbreak of glandular fever this year. 

Looking around me, I seem to see cases of 
glandular fever incubating all over the room. 
I do not think anyone who has listened to Dr. 
Lemann’s paper could doubt that these were in 
fact cases of glandular fever, and one must be 
a little envious of the careful and accurate rec- 
ords made of these patients. There occurs to 
my mind a nonsense verse, by Carolyn Wells, 
which may not be entirely inapropos to the too 
rash diagnosis of sporadic cases. It runs; 

“All children know, of course, the goose. 

See how they gather round the goose-giiTs knee. 
While she reads them by the hour 
From the works of Schoppenhauer. 

But do they understand what ’tis she’s talking 
’bout? 

Certainly not! Neither do they, neither does she. 
Nor, for that matter, did he!” 

Dr. I. I. Lemann (closing) : I think that 

patients with suppurating glands ought to be con- 
sidered as not belonging to this group, which has 
been called by some infectious mononucleosis. 

As to the tonsils being a portal of entry for 
the infection, as suggested: Two of our patients 

had tonstillectomies done, one before the first 
admission and the other between the first and 
second admissions. The tonsils were enlarged. 
This does not necessarily mean, however, that 
the tonsils were responsible for the enlargement 
of the cervical glands. Their enlargement might 
simply be part of the picture of lymph tissue in- 
volvement. 

As to the suggestion of both Drs. Jamison and 
DeBuys relative to an outbreak following epide- 
mic of influenza. Baldridge quotes Jamison in 
a recent article but could not find any evidence 
to bear out Jamison’s statement as to the rela- 
tion of influenza to glandular fever. 

To answer Dr. Fenner’s question; The glands 
were not tender nor painful. As to his implica- 
tion that perhaps the essayist did not know what 
he was talking about, I plead guilty. We knew 
we were dealing with an epidemic and knew it 
was marked. We did not have a caption to give 
it except fever of unknown origin. We were 
impressed by the universal adenitis. 

I sympathize with the plea of Dr. Fenner that 
we do not proceed to find a general epidemic of 
glandular fever. Please understand that we 
were dealing with a definite epidemic in a cir- 
cumscribed portion of the population. 


JAUNDICE OCCURRING IN 
UNTREATED SYPHILIS.* 

J. HOLMES SMITH, JR., M. D., 

New Orleans. 

It is the purpose of this paper to present 
several cases seen by me during the past 
four or five years in "whom icterus was a 
prominent symptom and apparently the re- 
sult of syphilitic involvement of the liver. 

Considering the volumes which have 
been written, in recent years, upon the sub- 
ject of jaundice, comparatively little atten- 
tion seems to have been paid to any 
relationship which may obtain between an 
existing icterus and syphilis as the etiologic 
agent. A possible explanation for this may 
lie in the fact that, while syphilis is a very 
common and widespread disease, obvious 
jaundice occurring during the course of 
otherwise readily demonstrable syphilitic 
manifestations, is comparatively rare. 

In Medical Clinic No. 15, at the New 
Orleans Charity Hospital, a clinic devoted 
to colored women and having a very large 
attendance, the percentage of new patients 
showing a strongly positive Wassermann 
is some times as high as 30 per cent, and 
we believe, in addition to this, that at least 
probably 40 per cent have syphilis as a 
background for their many complaints. Yet 
the number of jaundice cases from all 
causes is quite small. Of the cases show- 
ing jaundice, in the absence of positive 
Wassermann reaction, we at times assume 
syphilis to be the underlying cause and 
treat accordingly, but since jaundice fre- 
quently tends to be a self-limited condition, 
one must be quite guarded in making such 
assumptions. 

Considering the great prevalence of 
syphilitic infections, particularly in the 
colored race, it does seem strange that 
syphilitic involvement of the liver, and par- 
ticularly syphilitic jaundice are not more 
frequently diagnosed. 


*Read before Orleans Parish Medical Society, 
March 12, 1928. 


Smith — Jaundice Occurring in Untreated Syphilis 


195 


Concerning syphilitic liver disease, 
Osler(i) says: . “It is difficult to determine 
the frequency with which the liver is in- 
volved. Once attention has been called to 
the subject and the special features recog- 
nized, the cases are found to be not un- 
common ; in the records at the J ohns Hop- 
kins Hospital during a period of eighteen 
years there were 30 cases diagnosed as 
such, while in the post-mortem room among 
2500 autopsies there were 40 cases show- 
ing gummata or syphilitic cicatrices and 
15 additional cases regarded as syphilitic 
cirrhosis.” How different are the statis- 
tics of Warthin,(2) who has developed newer 
methods and criteria for the recognition of 
syphilitic infection. He says “out of 750 
autopsies at Ann Arbor there was evidence 
of syphilis in 300 cases or 40 per cent, and 
the liver showed chronic passive conges- 
tion and atrophy (brown atrophy chiefly), 
in every case.” The syphilitic lesions 
varied from slight plasma cell infiltration 
to brown atrophy, gummata, nd cirrhosis 
of various types. 

If Warthin’s figures are correct and 
there is greater or less liver damage in 
every syphilitic, it does seem strange that 
there is not more obvious evidence of it. 
It is not unlikely that the milder grades 
of involvement are being overlooked. 

Most references to syphilitic jaundice 
are found in the foreign literature, but 
several articles have appeared in American 
journals. 

In 1919, Scott and Pearson<3) reported 
two cases occuring during the secondary 
stage of the disease and six occurring 
within three weeks after inauguration of 
anti syphilitic treatment and attributed by 
them to a Herxheimer reaction. 

More recently, an article by N. Tobias<^> 
has appeared in the American Journal of 
Syphilis. 

It has been my fortune to observe five 
cases of jaundice in whom there seems 
little doubt that the etiologic factor has 
been the pale spirochete. Of these, four 


were in colored women and one in a young 
Mexican woman. In four the Wasser- 
mann reacton was strongly positive, and in 
one, negative; two of the cases were ob-^ 
served during the secondary stage of the 
disease and the other three during a later 
period. The cases, briefly, are as follows: 

Case 1.* E. P., colored girl, aged 15 years, first 
came to the clinic on April 6, 1925, complaining 
of yellow eyes and skin and dark urine, of two 
weeks duration. At this time she was looked upon 
as a case of catarrhal jaundice, was given so- 
dium phosphate and told to return in a week. 
Upon her return, one week later, the jaundice had 
become more intense and was pronounced in the 
sclerae, skin and soft palate; there was a macular 
eruption over skin of trunk and extremities; the 
epitrochlear lymphatics were quite prominent and 
the Wassermann reaction was strongly positive. 
At this time the urine contained a large amount 
of bile and the van den Berg reaction for rc- 
atined bile pigments was: Direct: prompt; indi- 
rect, 21 units, suggesting both an obstructive and 
a toxic or infective jaundice. The blood picture 
showed nothing of note except a slight increase 
in the total leukocytes to 10,250. The patient was 
given deep muscular injections of potassium bis- 
muth tartrate and bismuth salicylate. Her con- 
dition rapidly improved and on May 20 the van 
den Berg test showed. Direct 4.5 units (as 
against 17.5), and indirect 1.6 units. On July 1 
she appeared clinically well and stopped coming 
to the clinic. 

Before reporting the succeeding cases it 
might, perhaps, be well to make a few brief 
remarks regarding the treatment of these 
cases and the tests for bile pigments. 

Except in one case where mercurial rubs 
were employed in the early stage, all of 
these patients were treated by injections 
of bismuth preparations deep into the 
gluteal muscles. At first, potassium bis- 
muth tartrate was used but owing to the 
amount of local irritation which this prep- 
aration seemed to cause bismuth salicylate 
was substituted. In my opinion the arsen- 
ical preparations should not be employed 
where there is such evidence of liver 
damage. 

We have employed the van den Bergh 
test for retained bile pigments, routinely, 
because it is supposed not only to be a 
measure of the pigment retention but also 


196 


Smith — Jaundice Occurring in Untreated Syphilis 


to indicate the probable location of the 
trouble. The icteric index, while measur- 
ing the amount of retained bile pigments 
in the blood, serves no other purpose. 

No attempt has been made in these cases 
to employ any of the dye tests of liver 
function. In this connection, McVicar and 
Fitts, <5) of the Mayo Clinic, recently said 
“functional tests of the liver or pancreas 
have not yet attained diagnostic value in 
cases of jaundice.” 

Case 2. Mrs. C. I., white, Mexican, aged 21 
years, first reported at the clinic Feb. 13, 1928, 
complaining as follows: Two weeks previously 

she began having a dull ache all over her body 
and one week ago noticed eyes becoming yellow. 
For a week she had been vomiting about two 
hours after meals. No pain before or after food. 
Urine highly colored. Examination showed the 
sclerae to be markedly yellow; post cervical and 
epitrochlear lymphatics were easily felt; over 
skin of thorax, abdomen and extremities there was 
a marked macular eruption and the W assermann 
reaction was strongly positive. The urine at this 
time contained bile and some albumin and casts. 
The van den Bergh test showed; Direct reaction; 
delayed. Indirect, 30 units, indicating a toxic or 
infective hepatitis, but no obstructive lesion. She 
was placed upon bismuth therapy and has been 
responding very well. 

Case 3. J. P., colored woman, aged 50 years, 
first seen in the clinic Dec. 1, 1924. At that time 
her complaint was pain, radiating from the mid- 
dle of the sternum to the right costal margin and 
right axilla, accompanied by “dumb chills” and 
followed by fever. Duration three months. In 
addition to this she has had some jaundice for over 
a year and has lost about 30 pounds in weight. 
At times she has headache and dizzy spells. Her 
appetite was good, but she vomited all food taken. 
This would account for the loss in weight. 

Examination showed a decided icteric tint to 
the sclerae (this was before we were using the 
van den Bergh test and we have no measurements 
of bile pigments in her blood). Otherwise, there 
was little of note in the physical examination 
except: B.P. 160/110, and slight rigidity of the 
upper right rectus muscle. The urine showed the 
presence of bile. The Wassermann reaction was 
negative on Dec. 1, 1924, but strongly positive on 
Dec. 10, 1924. The blood picture showed a second- 
ary anemia. 

This patient was given several courses of mer- 
curial inunctions with iodid of potash and by Feb- 
ruary 23, 1925, she was markedly improved and all 
jaundice had disappeared. At a later date she 


was given bismuth salicylate and ultimately came 
to feel better than she had in years. 

Case 4. M. B., colored girl, aged 18 years, first 
seen April 20, 1927. At that time her complaint 
was jaundice of ten days duration which was in- 
creasing in intensity. She also complained of a 
painful swelling on the inner side of left thigh 
and a less painful one on the right thigh. These 
“swellings” were of the same duration as the 
jaundice. The history was otherwise unimpor- 
tant. Examination showed pronounced jaundice 
of sclerae, soft palate and skin. Left epitro- 
chlear only palpable lymph node. Nothing of note 
in heart or lungs. In the abdomen, there was 
some rigidity of the rectus muscles and satisfac- 
tory examination could not be made. There were 
no areas of tenderness. The liver and spleen 
could not be felt. On the inner side of left thigh 
was a painful, inflamed nodule about size of a 
walnut and a similar one, though painless, on the 
outer side of the right thigh. Wassermann re- 
action was strongly positive. Urine contained no 
bile. Van den Bergh test showed: Direct, de- 

layed; indirect, 2.5 units, indicating a toxic or in- 
fective process in the liver. 

She was given injections of bismuth salicylate 
twice weekly and by May 16 there was only a 
trace of icterus and the nodules on the thighs 
were about gone. Patient failed to return for 
further treatment. 

Case 5* M. B., colored woman, aged 35 years, 
came to the clinic June 8, 1925, with the following 
history: For about one year she had been feeling 

sick all over; had pains and aches over whole body 
which were worse at night; had frequent nausea 
but no vomiting; was constipated. Recently, she 
had noticed her eyes getting yellow. A history of 
two miscarriages was elicited with no other preg- 
nancy. Examination showed a fairly well devel- 
oped woman who appeared to have lost weight. 
There was a decided icteric tint to the sclerae and 
soft palate. About the centre of the soft palate 
was a small perforation such as is frequently seen 
resulting from syphilitic infection. No adenopathies 
were noted. There was nothing particular in chest 
except an accelerated heart rate. In the abdomen, 
the liver edge could be felt a short distance below 
the costal margin. There was some tenderness in 
the epigastrium. The spleen could not be felt. 
The Wassermann reaction was negative on three 
occasions. Urine contained bile with some albu- 
min and hyaline casts. Van den Bergh reaction 
showed: Direct, biphasic (prompt and delayed); 

indirect, 15 units, indicating a toxic or infectious 
condition causing both dysfunction of the liver 
cells and some obstruction. The blood picture 
was unimportant. This patient was placed upon 
bismuth therapy and by July 22 was clinically 
well, with no evidence of jaundice. She stopped 


Smith — Jaundice Occurring in Untreated Syphilis 


197 


coming to the clinic and we were unable to secure 
another van den Bergh test. 

This patient is being included in this series 
because I believe the evidence and results of 
treatment are proof of the syphilitic origin of her 
trouble, also, because she represents a type of case 
seen more frequently than the other members of 
this series. In this patient, while the Wasser- 
mann was negative, the other evidence was almost 
conclusive. 

It seems to me that any discussion of 
these cases should be preceded by a brief 
reference to the modern conception of 
jaundice and the van den Bergh reaction. 

McNee<®> has given, what is probably, 
the clearest, most concise and most easily 
understandable picture of jaundice, which 
has appeared in recent years. His conclu- 
sions are largely based upon recent studies 
concerning the relationship existing be- 
tween the parenchymal (polygonal) cells 
of the liver and the reticulo-endothelial 
system. In his study the van den Bergh 
test has played a prominent role. 

It has been found that jaundice is of 
two grades, first, that in which there is 
retention of bile pigments in the blood, in 
excess of normal, but not sufficient to be 
detected in the skin or sclerotics; this is 
known as latent jaundice; secondly, that in 
which the jaundice is visable to the examin- 
ing eyes. This excess of bile pigments is 
easily determined by the icteric index, but, 
theoretically at least, the van den Bergh 
test is superior because it not only records 
the amount of bile pigment present in the 
blood but as mentioned before is also a 
guide as to the probable location of the 
pathologic process. 

Using the van den Bergh test, it has 
been noted that bile pigments which have 
passed through the liver cells and been re- 
absorbed into the blood, as occurs in 
obstructive jaundice, will give a reaction 
very different from bile pigments which 
have not passed through the parenchymal 
liver cells. On this evidence two sets of re- 
actions have been evolved for the van den 
Bergh test; one, the so-called direct reac- 
tion, which when present indicates an 
obstructive condition somewhere distal to 


the liver cells, and the other, the so-called 
indirect reaction, which when positive in- 
dicates either damage to the liver cells 
(of a toxic or infectious nature) or an 
hemolytic process. On this hypothesis, the 
classification of jaundice into, first, ob- 
structive hepatic; second, toxic and infec- 
tive; third, hemolytic, gives us something 
which we can understand and which 
enables us to more correctly class our 
cases. 

Applying these ideas to the above cases 
we find that all give a positive reaction by 
the indirect method, indicating some inter- 
ference with the function of the liver cells. 
When we consider that the pathological 
process is most apt to involve the paren- 
chymal cells, it is rather to be expected 
that this reaction should be obtained. In 
addition, several cases gave a prompt di- 
rect reaction, indicating that there was 
some obstructive condition distal to the 
liver cells. 

It might be well to call attention to the 
fact that there must a rather widespread 
involvement of the liver cells (in cases of 
toxic and infectious jaundice) in order to 
cause considerable retention of bile pig- 
ments. Localized conditions, such as 
gummata, are not apt to cause any reten- 
tion of pigments and the van den Bergh 
and icteric index tests would be negative. 

Quite recently two cases of arsphenamin 
jaundice have come under my observation. 
It seems to me that if the administration 
of salvarsan were preceded by one or other 
of these tests for bile pigments (for such 
purposes the icteric index would be the 
simplest) we might be able to detect evi- 
dence of damage to the liver cells, avoid 
the use of salvarsan, at least until evidence 
of trouble had cleared up and so prevent 
such cases of jaundice. 


198 


Smith — Jaundice Occurring in Untreated Syphilis 


BIBLIOGRAPHY. 

1. Osier, Sir Wm. : Syphilis, Modern Medicine. Osler- 

McCrae, Vol. 2, 2nd edition, 1914. 

2. Warthin, A. S. : The new pathology of syphilis. Am. 

Jr. Syph., 2:424, 1918. 

3. Scott. G. O., & Pearson, G. H. J. : A preliminary 

report on syphilitic and arsenical jaundice. Am. Jr. Syph., 
3:628, 1919. 

4. Tobias, N. : Occurrence of jaundice in syphilitic 

patients. Am. Jour. Syph., 11:180-189, 1927. 

6. McVicar, A. S., & Fitts, W. T. : Clinical aspects of 

jaundice. J. A. M. A., 89:2018, 1927. 

6 . McNee, J. M.: Jaundice, a review of recent work. 

Quarterly Jour. Med., 16 :390, 1922. 

•Reported elsewhere — 

Smith, J. H., Jr.: Bismuth in treatment of visceral 

syphilis. Med. Cl. N. Am., Jan., 1926. 

DISCUSSION. 

Dr. J. H. Musser (New Orleans) : In diagnos- 

ing jaundice in liver disease it might be well to 
put down the four great causes of jaundice: 

1. Acute Yellow Atrophy. 

2. Diffuse Interstitial Hepatitis. 

3. Kinking of the Ducts or Obstruction of the 
Ducts. 

4. Acute Parenchymatous Hepatitis. 

Type 1 is extremely rare; in all I have seen but 
three cases. Type 2 gives us our syphilitic cir- 
rhosis, a relatively frequent disease (about 47 
per cent). Type 3 is due to obstruction of the 
ducts resulting in interference with the flow of 
bile; this may be caused by kinking, pressure, 
stone, fibrosis, or new growth. In Type 4 jaun- 
dice occurs early in the disease and there are 
various explanations for it. 

Dr. Smith has laid a great deal of stress on 
the importance of keeping away from arsphena- 
aiine in the treatment of these patients. His 
paper does not deal with the jaundice, but calls at- 
tention to the danger of giving the drug. This 
Hextheimer reaction occurs more frequently with 
syphilitic hepatitis than almost any other condi- 
tion. We also get in the treatment of this con- 
dition sometimes a paradoxical cure in which the 
patient has a moderate degree of ascites, but in 
which, despite the fact that the Wasserman is 
improving, go on with rapidity. I am very glad 
Dr. Smith called attention to this phenomena in 
jaundice and syphilis. I do not believe, however, 
it is quite as rare as he says. It is my impression 
that it is a bit more frequent. 

There is one difficulty, it is a very little diffi- 
culty, in the differential diagnosis of these condi- 
tions and that is the question of some other 
condition causing the jaundice in an individual 


with syphilis. It is not nearly as great a diffi- 
culty as it used to be on account of the routine 
use of the Wassermann reaction. In the old days 
I know of four or five cases where the patient was 
operated on for cholecystitis, gall-stones and such 
conditions and it turned out that the trouble was 
not with the gall-bladder but a syphilitic hepatitis. 
Given a person with a positive Wassermann in the 
present day we would suspect the possibility of 
syphilitic disease causing jaundice. It must not 
be forgotten that an acute intercurrent disease, 
and not syphilitic hepatitis, may be the cause of 
the jaundice. I remember a case which impressed 
me very much. The patient had an acute inflam- 
matory lesion of the abdomen, generalized pain, 
nausea, and vomiting, but she was refused opera- 
tion because she had syphilitic cirrhosis. She 
died of a ruptured gall-bladder. Of course, the 
Wassermann reaction was positive. The same 
thing applies to acute infectious jaundice. There 
are many cases of jaundice supposed to be acute 
hepatitis which nevertheless, as in this case, may 
be unrelated to the syphilitic lesion. 

Dr. F. M. Johns (New Orleans) : I have been 

very much interested in Dr. Smith’s remarks on 
the van den Bergh reaction. We realize the su- 
periority of this test in checking cases of hepati- 
tis and I really believe that it could be put to a 
more generalized use. It should be correlated 
with the urine test for biliverdin. It has oc- 
curred to me that in severeal cases I was able 
to detect bile pigment in the urine before the 
indirect van den Bergh could be demonstrated. 
With an indirect van den Bergh reaction of 24 
to 26 units, which would indicate an extensive 
parenchymatous degeneration of the liver, you will 
always be able to demonstrate biliverdin in the 
urine with Schlesesinger’s test which is very easy 
to perform and which I would recommend in 
those instances in which the more complicated 
blood test is not feasible. 

Dr. Abe Mattes (New Orleans) : In the last 

five or six years I have had occasion to see in the 
clinic at Charity Hospital syphilis in all its phases, 
including jaundice. We had six or seven cases 
of jaundice that were not given bismuth therapy 
but were subjected to routine salvarsan admin- 
istration. There were no tests made, as described 
by the author and though salvarsan may be con- 
traindicated in these cases, there was nothing of 
note in this series, for no complications arose. 

I regret not knowing the relationship between 
toxic hepatitis and the damage that salvarsan may 
do, but as there was no apparent harm resulting 
from the measures that are employed in early 
secondary syphilis, I am grateful. 

Dr. J. Holmes Smith, Jr. (closing) : Probably 

Dr. Musser misunderstood me about the frequency 


Walther — Modern Treatment of Gonorrhea 


199 


of jaundice in syphilis. What I stressed was the 
fact that I found only five cases of jaundice in 
the skin that I was willing to accept as due to 
syphilis. However, there are a number of cases 
coming in with obvious jaundice. We treat them 
accordingly, but have no proof that the jaundice 
is due to syphilis. Many come in, receive no 
treatment, and get well. 

With regard to jaundice and the Herxheimer’s 
reaction, recently in our clinic we have had three 
or four cases come back from salvarsan clinic 
with very pronounced jaundice. Only a week ago 
a patient reported to the clinic, intensely jaun- 
diced, who had received two doses of the drug and 
had to go to bed for a month before she could 
come to the clinic. We try to run an icteric index 
on patients with positive Wassermanns. We are 
using the van den Bergh test on account of its 
supposed value to give us an idea as to whether 
the jaundice is due to obstruction, to a toxic 
condition affecting the liver cells, or whether it 
is hemolytic in origin. 

With regard to Dr. Mattes’ remarks, I have seen 
cases in the ward with positive Wassermanns given 
salvarsan and suffering ho apparent ill effects, but 
knowing the effect of salvarsan on the liver, I 
think it wise to give bismuth and later on, as 
the condition improves, possibly the salvarsan 
would be in order. 

MODERN TREATMENT OF 
GONORRHEA.* 

H. W. E. WALTHER, M. D., 

New Orleans. 

It is a source of wonderment to many 
urologists that so many members of the 
medical profession still adopt a most indif- 
ferent attitude towards the subject of gon- 
orrhea. In some localities the physicians 
openly announce that they do not treat 
cases of Neisserian infection. In far too 
many instances, where physicians do ad- 
minister treatment for this infection, it is 
carried out in so haphazard a manner as 
to be of little avail. Just where to place 
the blame is a difficult matter. Whether the 
physician was trained improperly while at 
college ; whether the text-books confuse 
him rather than elucidate a rational thera- 
peutic scheme; or, whether the urologists 

*Read before the Tri-County Medical Associa- 
tion, McComb, Miss., March 13, 1928, and before 
the Third District Medical Society, St. Martin- 
ville. La., June 28, 1928. 


themselves, in their enthusiasm to bring 
before their confreres the more spectacular 
phases of their surgical progress, have 
failed in their duty of properly keeping 
the profession abreast of the time — this 
is a matter for some one better qualified 
than myself to explain. However, I cannot 
but feel that the urologist is to blame for 
much of the misunderstandings within our 
professional ranks as regards the status of 
gonorrheal therapy as practiced today. It 
shall be my purpose to clarify, as best I 
can, the situation even if we must limit our 
discussion to the bare essentials. 

Before entering upon the subject of 
treatment I trust you will indulge me a few 
moments while I recall to your minds a 
few facts upheld by statistics gathered 
from sources the reliability of which can- 
not be questioned. In the first place vene- 
real diseases generally are not on the de- 
crease. There is to be found today just 
as much, if not more, gonorrhea among 
men, women and children as was observed 
twenty-five years ago. This in spite of the 
fact that sex hygiene i^ today to be found 
in the school curriculum of every child in 
the land. Much propaganda in the form of 
moving pictures, stage plays, lectures, 
books, posters, and the like, have for years 
been directing the attention of the youth 
of the country to the ravages that follow in 
the wake of the venereal peril. And still 
fresh cases of gonorrheal infection daily 
knock at our office doors for help. Then 
viewing the problem from an economic 
standpoint the time lost by the wage-earner 
infected with gonorrhea, not only as meas- 
ured in dollars lost to his needy family, but 
also as applies to the material loss of his 
services to his employer and the disruption 
such illness causes to his organization, 
mounts yearly into stupendous figures. 
Surely the treatment of gonorrhea should 
vitally interest all of the members of our 
calling. Let us awaken to the situation 
existing today. The age of jazz is in no 
wise conductive to better morals. We 
must, therefore, study seriously how more 
effectively to combat this diseai^e in its 


200 


Walther — Modem Treatment of Gc<norrhea 


early stages, in both sexes, so that a mini- 
mum number of complications will be ob- 
served, When complications intervene we 
must be capable of recognizing them 
promptly so that efficient treatment can be 
summarily instituted. 

To diagnose accurately gonorrhea we 
must employ the microscope. I would 
scarce have the courage to mention this 
point before such an audience were it not 
for the fact that ever so often where the 
clinical evidence of a discharge was ac- 
cepted by certain physicians as sufficient 
proof of gonorrhea, valuable time was lost 
in arresting the ravages of an urethral 
chancre. A sterile urethral smear should 
make one suspicious therefore of urethral 
syphilis and careful palpation of the 
urethra, possibly an endoscopic study, ob- 
serving for secondary manifestations, and 
a blood Wassermann should be employed 
in aiding to clear up the diagnosis. S© 
much for the male. 

In women the term leucorrhea has been 
handed down to us from time immemorial 
with all the dignity accompanying a clini- 
cal entity. Yet today most of us should 
realize that so-called leucorrhea is but a 
symptom, not a disease. The time-honored 
vaginal douche therefore is about as valu- 
able in the treatment of gonnornhea ojf 
women as is the methylene blue pill in 
men. 

The first principal we must accept, if 
we are to treat our cases of gonorrhea 
along the lines of modern urologic teaching, 
is that the infection perpetuates itself by 
gaining lodgment in certain gland struc- 
tures. Our theraphy is therefore directed 
at eradicating these foci of infection. In 
the male the paraurethral glands, the peri- 
urethral glands, Cowper’s glands, the 
prostate and the seminal vesicles deserve 
special consideration. In the female the 
vulvo-vaginal or Bartholin glands, Skene’s 
glands and the cervical glands demand par- 
ticular attention. 


Any number of concurrent factors may 
be met with in the treatment of gonorrhea 
which, when ignored or allowed to go un- 
recognized, may add materially to the 
chronicity of a given case. I refer particu- 
larly to phimosis, balanitis, venereal warts, 
urethral caruncle, pin-point urethral 
meatus and stricture. At one time the 
teaching was to treat the infection first 
and then attend to these other coexistent 
factors later. I have never understood the 
rationale of such reasoning. We attend 
to these matters first. It saves time and 
much worry. Wliere a foreskin is so tight 
that the urethral meatus cannot be easily 
exposed, circumcision is done at once. Only 
in this way can balanitis be promptly ar- 
rested. Venereal warts or urethral car- 
uncles are promptly destroyed with the 
high frequency spark. Meatotomy is done 
at once where the meatus is found stenosed. 
Strictures must be dilated in order to 
further urethral drainage; naturally I re- 
fer here to strictures of the anterior 
urethra mainly as it is constrictions of this 
type that hinder any form of therapy di- 
rected at controlling acute infections of 
this area. 

TREATMENT OF THE MALE. 

Urethritis. More misleading statements 
are made by the manufacturers of drugs 
that are supposed to be specifics for gonor- 
rhea than probably can be observed of any 
other group of remedies. Hardly a week 
goes by but we receive through the mails 
announcements that at last something 
wonderful has been discovered that will 
promptly cure ijnfections of the diplococcus 
of Neisser, Few of us today are fooled by 
rash claims. All of us hope to see the day 
when we will have a true specific here. So 
far, however, it has not come to hand. 
Within twelve hours after exposure, the 
organisms begin their siege by burrowing 
into the many follicles that stud the ure- 
thral lumen throughout its length and soon 
are safely hidden away beneath a barrier 
difficult for any agent to penetrate. In 
rare instances we observe cases who report 


Walther — Modern Treatment of Gctnorrhea 


201 


within the first twelve or twenty-four hours 
after noting a discharge and here abortive 
treatment with a single injection of 2 per 
cent silver nitrate solution following a 1 
per cent cocain local anesthetization will 
frequently effect a cure. But these cases 
make up a small percentage of all gonor- 
rheas seen, probably not more than 1 per 
cent. The druggist sees most of these 
patients first. Later the physician. The 
antiseptic dyes, one of the few good things 
accruing from the World War, unquestion- 
able are far superior to the older protein 
silver preparations. ^ The penetrating 
quality of the dyes, whereas not fullfilling 
perfectly our requisites of what an ideal 
gonococcicide should be, commends itself 
to our favorable consideration. We should 
employ them intensively at the present 
time. One-quarter per cent pyridium solu- 
tion, mercurochrome in 0.5 per cent 
strength and neutral acriflavine in 1:2000 
dilutions should be used alternately. Bac- 
teria of any strain ultimately acquire a 
certain degree of tolerance against any 
one given drug. Therefore by using one 
dye solution on one day and switching to 
another the next maintains better the 
therapeutic efficiency of each drug. It is 
imperative that fresh solutions be made up 
daily. Old solutions not only lose in po- 
tency by being kept indefinitely on the 
shelf, but they are also found to be far 
more irritating than freshly prepared solu- 
tions. 

The quest for a dependable internal 
urinary antiseptic has proceeded uninter- 
ruptedly through the years. Up until the 
introduction of pyridium I personally could 
not enthuse over any of them. During the 
past twelve months my experiences with 
administering pyridium by mouth to cases 
of gonorrhea has forced me to modify my 
opinion. This collodial conde??.sation prod- 
uct of phenyl-azo-diamino-pyridine-hydro- 
chloiTide, known as' pyridium, is a most 
valuable internal urinary antiseptic. Its 
influence upon bacteria and pus is practi- 
cally immediate. The more acute the in- 


fection the more prompt will be the action 
of the pyridium. Two tablets, of 0.1 gm. 
each, are given three times a day. The dye 
stains the urine a brownish-red; the secre- 
tion from the prostate and seminal vesi- 
cles also is colored following the taking of 
pyridium. No internal urinary antiseptic 
so far given us will, with the same prompt- 
ness, clear the urine of pus and bacteria. 
In gonorrheal infections it serves as an im- 
port aid in promtly getting the case under 
control. It should be needless to add that 
local treatment is never to be subjugated to 
internal medication, but is to be employed 
along with the local remedies mentioned in 
the preceding paragraph. Furthermore, 
where the chronicity of a urinary lesion is 
due to some mechanical obstructive factor, 
something more than internal medication 
is obviously demanded. 

Self-treatment is always disappointing, 
even in the hands of the most intelligent 
patient. Either he gives himself an injec- 
tion improperly, is in too great a haste or 
because of the pain accompanying the in- 
jection he does not use it at all, but mis- 
leads his physician into believing that he 
is carrying out instructions to the letter. 
The doctor must personally institute the 
therapy in Neisserian urethritis. If he is 
too busy to do this, he should turn the case 
over to a physician who will. 

Every dram or two instilled into the 
urethra must be held in for at least ten 
minutes ; in some cases fifteen minutes soak 
is better. A meatus clamp is handy here. 
For the first few days the patient reports 
to the office morning and afternoon. There- 
after once daily usually will suffice. At 
each visit patient reports with full bladder 
and voids in two glasses. This test, crude 
though it may be, gives sufficient clinical 
information for the practitioner to know 
whether or no the infective process has 
passed behind the compressor urethrae and 
invaded the posterior urethra. I never give 
a local treatment for active gonorrhea un- 
less the patient can first flush out the ure- 
thra with urine. I believe this procedure 


202 


Walther — Modern Treatment of Gcaorrhea 


minimizes the number of complications 
which are apt to ensue. Smears under the 
microscope are checked with the Gram 
stain twice weekly. 

A suspensory bandage is prescribed at 
the first visit for obvious reasons. A com- 
plete list of instructions of “dos” and 
“donts” are also given patient at this time. 
If the doctor will place all of his cards on 
the table at the first interview there can 
be no chance of misunderstanding. 

Posterior Ureth^'itis. Most cases of an- 
terior urethritis develop a posterior in- 
volvement within a week after initial onset 
of symptoms. The prompt recognition of 
this complication means much if results are 
desired. Observing a cloudy second glass 
of urine and a complaint upon the part of 
the^ patient of frequency and urgency 
should immediately place one on guard. 
Irrigations are more harmful here than 
any other procedure you might use. More 
traumatism, with subsequent stricture for- 
mation, is produced by ill-advised, forceful 
irrigations than by any other means I 
know of. Eighteen years of experience in 
urological work has taught me the futility 
of the irrigation method of treating gono- 
coccal urethritis. Instillations of a dram 
of a 2 per cent solution of silver nitrate 
administered by means of a Guyon woven 
silk, olive tipped catheter specially designed 
for the purpose, serves as a specific where 
the condition is gotten sufficiently early. 
But in any case 2 per cent silver instilla- 
tions are superior to any other medication 
in the posterior urethra. These are given 
twice or thrice a week, depending upon the 
severity of the case and the reaction fol- 
lowing its use. By having the patient 
supine on the treatment table, with the 
bladder empty, we can in most instances 
gently install a solution of mercurochrome, 
pryridium or neutral acriflavine into the 
posterior urethra by means of a two dram 
urethral syringe. In the process of injec- 
tion the patient is asked to relax as well 
as to go through the act of voiding. This 
relaxes the sphincters and the medicament 


passes easily into the posterior urethra 
and bladder. 

Paraurethritis. Laterally to the ure- 
thral meatus and on the glans one not 
infrequently will observe a minute duct 
opening. The orifice of such a gland in- 
fected with gonococci will be found red 
and puffed and upon pressure will dis- 
charge a small drop of pus rich in organ- 
isms. Unless the clinician is on the look- 
out for these foci they might easily be 
missed. They serve as one factor in the 
perpetuation of so-called intractable ure- 
thrites. These glands are easily destroyed 
by one application of high frequency spark. 

Periurethritis. An occluded periure- 
thral gland may go on to abscess formation 
and, if left alone, may rupture either on 
the skin or into the urethra. Incising 
these abscesses should not be done hastily. 
The dread of a resultant permanent ure- 
thral fistula from such surgical interven- 
tion must ever be kept in mind. If the 
abscess points urethrally, it can best be 
opened through an endoscope with high 
frequency spark. Should the abscess point 
superficially, needle aspiratory puncture 
plus the injection of a few minims of a 1 per 
cent mercurochrome solution will usually 
bring about prompt resolution of the pus 
focus. The expectant treatment is with 
hot fomentations. If periurethal infiltra- 
tions assume tiny, shot-like feeling masses, 
they are treated by massaging them over a 
straight sound twice weely until they dis- 
appear. 

Cowperitis. There are two compound 
tubular glands situated between the two 
layers of the triangular ligament, anteri- 
orly to the prostate, known as the bulbou- 
rehral or Cowper’s glands, which have 
hitherto received little consideration by the 
clinician. When involved they can be 
easily palpated by placing the index finger 
within the rectum and pressing the thumb 
against the perineum. Many cases of in- 
tractable gonorrhea unquestionably are due 
to foci hidden away in Cowper’s glands. 


Walther — Modern Treatment of Gonorrhea 


203 


Unless they abscess little attention is paid 
them by the average doctor. Every male 
with chronic gonorrhea should be examined 
for Cowperitis. Massage to the perineum 
and the application of heat often produces 
pleasing results. Diathermy to the peri- 
nuem has materially helped me clear up 
these foci which are so inaccessible. Ab- 
sceses obviously must be drained surgi- 
ally. 

Prostatitis. This complication of chronic 
infection by far makes up the bulk of the 
urologist’s office work. We know that the 
great majority of urethral infections go 
posterior sooner or later, and authorities 
agree that posterior urethritis and pros- 
tatitis always go hand in hand. Only too 
few men take sufficient pains with their 
cases to make rectal examinations and to 
study the expressed secretion microscopi- 
cally. The usual excursion of the index 
finger in carrying out massage is a swing 
from the lateral extremity of the gland 
towards the mid-line, downwards and out- 
wards. The prostate, as you will recall, 
lies on the floor of the rectum just within 
the anal sphincter. Any physician, with a 
little practice, can acquire the proper 
stroke. Massage is superior to all other 
forms of therapy in prostatitis and is car- 
ried on, every day, until the secretion is 
free of pus and bacteria. This may re- 
quire two months of treatment ; it may take 
a year. 

Seminal Vesiculitis. These structures 
are invaded with the gonococcus frequently 
and again massage is our mainstay. Be- 
cause of the difference in glandular struc- 
ture, the vesicles are emptied differently 
from the prostate. Here the finger adopts 
a downward and zigzag movement in order 
more effectfully to empty the sacs. If one 
want^ to collect the prastatic and vesicular 
secretions separately the prostate is first 
massaged on a full bladder; the patient 
then empties his bladder and the vesicles 
are massaged and the secretion collected in 
a separate receptacle. Besides massage 
diathermy is used in the obstinate types of 


both vesiculitis and prostatitis. No perfect 
electrode has yet been devised for this work 
but the V-shaped instrument that is placed 
via the rectum against the prostate with 
the other blade resting on the perineum is 
superior to others. 

Stricture. With the more universal 
adoption of less cauterizing antiseptics and 
with a truer appreciation of the value of 
gentleness in all urethral manj’pulations, 
strictures are becoming rarer every year. 
Still they are met with and one never knows 
when he might have a patient with gonor- 
rhea who harbors a congenital stricture. 
Silk bougies are far less traumatizing than 
steel sounds, and are becoming more popu- 
lar all the time. The Kolmann dilator has 
a definite place in the treatment of stric- 
tures, particularly those at the bulb. Dila- 
tation here serves a dual purpose in that it 
relaxes the annular scar within the urethra 
and at the same time massages the prostate 
from within. 

Epididymitis. No complication of Neis- 
serian infection is more painful than epi- 
didymitis. Nothing yet discovered relieves 
this pain as promptly as diathermy. This 
modality of physiotherapy does not only 
relieve the pain, but if applied sufficiently 
early, will reduce the swelling more rapidly 
than can be accomplished by other agents. 
The intramuscular injections of foreign 
proteins or the intravenuous injection of 
mercurochrome serves as an added meas- 
ure in relieving the more refractive cases. 
Epididymotomy is rarely practiced now. 
Diathermy has materially reduced the 
number of epididymi that go on the abscess 
formation. Naturally when abscesses de- 
velop incision and drainange becomes im- 
perative. 

Arthritis. This complication too often 
brings in its wake much suffering. Here 
again diathermy is the best agent at our 
command for promptly relieving pain and 
swelling. Foreign preteins intramuscu- 
larly or mercurochrome intravenously aid 
in many cases to hasten resolution. As- 


204 


Walther — Modern Treatment of Gonorrhea 


piratory puncture to relieve the joint of 
fluid is being used less and less. Open op- 
erations on the joints are never practiced 
in my clinic. We depend upon rest and dia- 
thermy chiefly to promptly arrest the pro- 
cess. After all is said and done results will 
follow only if the primary focus of infec- 
tion is recognized and efficiently treated. 
As the prostate and seminal vesicles are by 
far the chief offenders here, they must be 
treated assiduously. 

TREATMENT OF THE FEMALE. 

As the urologist deals alone with the 
lower portion of the urogenital tract in 
women, infection of the uterus, tubes and 
ovaries will not be considered here. They 
truly belong within the sphere of the gyne- 
cologist. 

Any number of physicians are of the 
belief that gonorrhea in women is incur- 
able. This, of course, is fortunately not 
true. If we seek out the foci infected with 
the gonococcus and apply rational thera- 
peutic measures, provided we can enlist 
the whole-hearted co-operation of the 
patient, results are most satisfactory. 

Bartholinitis. The vulvo-vaginal or Bar- 
tholin glands become infected in cases of 
gonorrhea in about 40 per cent of patients. 
Occasionally abscesses occur in these 
glands in neglected cases. Excising these 
glands I consider poor surgery. Such pro- 
cedure exposes lymph channels which most 
often disseminates the infection rather 
than arresting it. The application of dia- 
thermy by means of the needle elecrtode in- 
serted into the duct and gland sterilizes 
both in a few seconds. The after care con- 
sists of topical applications of 10 per cent 
mercurochrome. 

Skenitis. Infections persist longest in 
the anterior third of the female urethra 
and this is attributable largely to diseased 
Skene’s glands. Again the diathermy 
needle, employed through an urethral 
speculum or better through an electrically 
illuminated skeneoscope, is the most valu- 
able agent we have to sterilize these foci. 


Usually one gland is treated at the time. 
Within three days or a week the other is 
destroyed. This is done so as to avoid an 
undue amount of reactionary edema. The 
follow-up care is with 5 per cent mercuro- 
chrome. Dilatations to urethra once 
weekly, until we reach instruments of 30 
or 32 F., are necessary following diathermy 
and mercurochrome therapy. 

Endocervicitis. So much has been writ- 
ten within the past few years on diathermy 
and its value in endocervicitis that we need 
say little here. It is the one and only sure 
way to destroy gonococcal infections of the 
cervix and at the same time in no way in- 
jure tissue. Sufficiently intense heat will 
kill gonococci ; that we know. With elec- 
trothermic high frequency we can obtain 
this needed degree of heat, within the tis- 
sues, for periods sufficiently long to destroy 
the bacteria. 

CONCLUSIONS. 

1. Gonorrhea perpetuates itself over in- 
definite periods of time by gaining lodge- 
ment in certain uro-genital gland struc- 
tures. Only by searching carefully for 
these foci and then administering the 
proper treatment, over a sufficient period 
of time, can a cure of the infection be ef- 
fected. 

2. The newer dye antiseptics, pyridium, 
mercurochrome and neutral acriflavine in 
particular, seem to offer us mcch as agents 
which penetrate the tissued invaded by the 
gonococcus. Silver nitrate is by far the 
most reliable antiseptic we have for treat- 
ing these infections. Instillations are far 
less traumatising than irrigations and are 
to be preferred as the most satisfactory 
means of applying these drugs. 

3. Intramuscular injections of foreign 
protein substances and intravenous injec- 
tions of small doses of mercurochrome 
serve as valuable adjuncts in the treatment 
of refractive cases. Small doses of neoarc- 
phenamine, frequently repeated, some- 
times give results when the above men- 
tioned agents fail. Vaccines have proven a 


Bessesen — Medical Therapy of GaH Bladder Disease 


205 


complete failure in the treatment of gonor- 
rhhea and are not to be recommended. 

4. Diathermy offers us an extremely 
wide field of usefulness in the management 
of these infections. In infected gland struc- 
tures of the urethra of both sexes it is most 
satisfactory. In the prostatitis it has a 
fixed place. For acute gonococcal epididy- 
mitis it is the nearest thing to a specific 
that we have. In sterilizing Bartholin, 
Skene or cervical glands in women, it has 
no equal in the therapeutic field. Diathermy 
to painful, swollen gonorrheal joints 
promptly relieves symptoms. 

5. Therapy directed at relieving any 
disease, no matter how efficiently executed, 
may fail due to the lack of proper co-opera- 
tion on the part of the patient. The patient 
should be made to realize the seriousness 
of his or her infection and told of the pos- 
sibility of resultant sterility or chronic 
invaljdism where treatment is neglected. 
Sexual intercourse, alcoholic drinks and 
exercise are interdicted. Where the patient 
is married (and fully GO per cent of our 
patients are married) the opposite party 
should be interviewed, when necessary ex- 
ami^ned, and if found infected, treated. 
Matters such as these, tactfully handled, 
should cause no disruption in marital fe- 
licity and are essential if a cure is to be ex- 
pected. 

6. Gonorrhea is curable and the means 
for dispatching these infections is accessi- 
ble to all. The urologist has no secrets to 
hide from the general practitioner. No 
magic formula exists that will do the im- 
possible. As in most phases of medicine, 
common sense plays a major part. Let us 
show more interest in the management of 
venereally infected patients. 


MEDICAL THERAPY OF GALL BLAD- 
DER DISEASE. 

ALFRED N. BESSESEN, JR., M. D., 

From the Bessesen Clinic, Minneapolis 
Minneapolis, Minn. 

Diseases of the gall tract and liver are 
very common, and in their early stages are 
frequently overlooked. Ajvarez states that 
from 5 per cent to 10 per cent of all women 
coming to autopsy have gall stones. Menker 
records that in six hundred and twelve con- 
secutive necropsies in persons over twenty- 
one years of age, 66 per cent showed some 
pathology, though but 5 per cent com- 
plained of symptoms. Fisher and Snell 
found 40 per cent gall bladder pathology in 
two hundred abdominal operations. 

The liver, gall bladder, bile tracts, stom- 
ach duodenum and intestines are all derived 
from the primary entoderm,. The liver de- 
velopes as an anlaga from the duodenum 
and the gall bladder as a diverticulum from 
it. The gall bladder is guarded by a spiral 
duct and the common duct by the sphincter 
of Oddi. The gall bladder has a capacity 
of about 50 cc. and its walls are composed 
of fibrcelastic tissue and smooth muscle, 
which is arranged in three layers, longi- 
tudinally, circularly and obliquely. Freese 
states that the pressure exerted in empty- 
ing the gall bladder is 220 mm. of water, or 
about the same as the secretion pressure 
of the liver. The liver secretes bile con- 
tinuously which is held back by the sphinc- 
ter of Oddi, flowing back into the gall blad- 
der. The gall bladder concentrates the bile, 
and on stimulation of the sphincter of Oddi 
it flows out to take its part in digestion. 

Most diseases of the liver and gall blad- 
der are due to infection, some are due to 
disturbed cholesterol metabolism, and some 
to malignancy. Infection reaches the bili- 
ary system through the following means: 
through the hepatic artery from foci of in- 
fection as the teeth, tonsils, sinuses, etc.; 
through the portal system from the intes- 
tinal tract; through direct extension from 
the duodenum, which does not frequently 


206 


Bessesen — Medical Therapy of Gall Bladder Disease 


occur ; by contiguity, namely from other in- 
fected organs, transperitoneally, which is 
probably rare. 

Acute diseases may be limited to the gall 
bladder, but the chronic stages are rarely 
so, and are shared to a greater or less 
degree with diseases in the liver, pancreas, 
stomach, duodenum, intestines and appen- 
dix. Infection in the gall bladder may 
start suddenly with pneumonia, typhoid 
fever, acute sore throat, etc., or insidiously 
with the gradual feeding of the infected 
blood from some focus to the liver and gall 
bladder wall, which removes the bacteria to 
protect the body, finally itself falling in- 
valid to it. Inflammation may start in any 
part of the gall tract and may clear up Leav- 
ing focalization behind which most com- 
monly is in the gall bladder due to the fact 
that there is more or less stasis here all the 
time. The infected gall blalder may clear 
up only to be reinfected. Lyons gives three 
vicious cycles which make it difficult for 
the gall tract to clear itself : 

1. Mural infection in the wall of the gall 
bladder which then becomes a definite focus 
and sends the infection through the lym- 
phatics to the liver and pancreas, and from 
both of these it is sent back to the gall blad- 
der. This type, he thinks, will not get re- 
sults from drainage, but 70 per cent to 85 
per cent will get results from surgery, if 
performed by capable men. 

2. The dissemination of the infected 
and poisoned bile through the intestinal 
wall, which may develop a mural infection 
into the mesenteric vessels and from there 
to the portal system into the liver, part 
going through the interior vena cava into 
the heart, and from there to the entire 
body. 

3. Similar to the second, and represents 
the infected and poisoned bile being taken 
up by the lacteals into the cysterna chyla, 
into the left inominate or subclavian vein 
to the heart, and then pumped to the body, 
finally getting to the liver and adding 
another burden to the already injured 
organ. 


Infection of the biliary system may have 
its beginning in childhood or early youth 
and may be classed into a period of infec- 
tion, a latent period and a stage of compli- 
cations. 

The stage of inception may be instituted 
by an acute fulminating disease with high 
temperature, severe pain, nausea, vomit- 
ing, jaundice and tender liver, or may come 
on gradually and make it impossible to get 
a history of a definite beginning. 

During the latent period the patient suf- 
fers little discomfort with occasional flarer 
ups, mild jaundice, indigestion, a dull pain 
under the right ribs, which is aggravated 
on exertion or stretching and may extend 
to the back or up under the right shoulder 
blade. There may be mild nausea and much 
gas distress with or without heart burn. 
There is apt to be constipation and dopey 
headaches, bad breath or bad taste in the 
mouth or occasional vomiting of sour green 
bile, or regurgutation. All may be more 
or less indefinite and transient. 

With the stage of complications, one ob- 
serves adhesions, stones, obstructions, pus, 
perforations, peritonitis and pancreatic in- 
volvement. 

To secure a diagnosis, the history is very 
important and must be thorough, going into 
the early symptoms for signs of gastro-in- 
testinal trouble. In examination, the press- 
ing of the fingers into the relaxed abdomen 
under the right costal margin and having 
the patient breathe deeply may elicit pain 
wlien other signs fail. A fractional gastric 
study should be made and the biliary sys- 
tem drained and the bile examined micros- 
copically and bacteriologically. A great 
deal may be learned from this study, the 
amount of information being dependent on 
the ability and experience of the physician. 
The finding of pus and bile-stained epithe- 
lium can be diagnosed easily. Due to the 
brevity of this paper I will not go into the 
discussion as to whether the gall bladder 
can be drained or as to why the bile flows. 
There is a great difference of opinion 


Bessesen — Medical Therapy of Gall Bladder Disease 


207 


among investigators on this subject, but 
these facts remain dominant, that the bile 
flows and flows easily to the stimula- 
tion of magnesium sulphate, peptones, 
ohve oil, etc.; that in most cases three 
types of bile are obtained, the A, B, 
and C bile, and where not obtained 
pathology may be suspected; that with 
the flow of bile the gall bladder must 
empty to a greater or less degree depending 
upon the strength of the stimulus ; and that 
nearly all men agree that more or less 
benefit is obtained symptomatically by the 
drainage. Roentgen-ray examination is 
important and is more accurate since the 
tetrabromiodophenolphthalein test has been 
used as an aid in diagnosis. In certain 
cases the use of the liver function test and 
blood chemistry may be of value. 

In the treatment of all types and condi- 
tions of gall bladder disease, it is well to 
observe certain factors. All foci of infec- 
tion which may be feeding the lesion must 
be cleared or removed. It is impossible to 
get results surgically or medically unless the 
source is eradicated. This applies to the 
teeth, tonsils, sinuses and upper respiratory 
tract, especially, but also to chronic bron- 
chitis, diseases of the intestines, prostatitis 
and uterine diseases. The body must be 
placed in the best possible condition to over- 
come its invasion. The infection in the 
bile passages and gall bladder must be 
eliminated. Regular and thorough drain- 
age of the biliary tract must be established 
and maintained. Complications must be 
averted. 

Acute cases of gall bladder disease are 
medical, and surgery when necessary 
should be done in the interim. The fol- 
lowing treatment depending upon the 
severity of the attack should be instituted. 
Auto-lavage of the stomach by letting the 
patient drink warm water and throw it 
up until it returns clear. This cleans and 
soothes the inflamed mucus membrane. 
Heat is applied to the right upper quad- 
rant by means of hot water bottles elec- 
tric pads or electric lights. Counterirrita- 


tion may give relief in the form of mus- 
tard packs or plasters. In severe cases 
where a bad infection or an empyema is 
suspected the side should be packed in ice 
and kept so until the symptoms clear. It 
is in this type of case that surgery gets 
its highest mortality as well as many of 
its bad results and should not be used 
except as a last resort. It is true that all 
cases will not recover with this treatment, 
but the mortality will be much less than if 
treated surgically. If nausea persists after 
auto-lavage ten to fifteen drops of chloro- 
form in a small amount of ice water can 
be given. Morphin will have to be used 
in some cases. No food should be taken 
for twelve to eighteen hours until the nau- 
sea and distress is relieved, and food 
should be started slowly with weak tea, 
gruels, skimmed milk or buttermilk, and 
added to gradually. Hexamethylenamin 
should be given in all infections in doses 
of fifteen grains three times daily for 
three days and at intervals until well. 
The urine must be watched for albumin as 
the drug used over long periods will injure 
the kidneys. This drug is excreted by the 
liver and gall bladder wall and is anti- 
septic. Salts should be given one half hour 
before meals as they neutralize the acid 
and reverse the osmotic pressure, drawing 
the fluid from the inflamed mucus meim- 
brane, reducing the engorgement. They 
also stimulate the gall bladder and liver. 
In cases of stone, the salts may cause in- 
creased pain and should not be used if this 
occurs. Salts have been recognized for 
centuries and form the method of treat- 
ment that thousands of patients receive at 
the springs and sanatoriums. Much can be 
done by the judicious use of salts, a good 
mixture being equal parts of magnesium 
sulphate, sodium sulphate, and sodium bi- 
carbonate; a teaspoonful in warm water. 

The subacute and early chronic cases 
should be treated during exacerbation in 
a similar way, but in the interim they 
should receive care as well. This should 
consist of : 


208 


Bessesen — Medical Therapy of Gall Bladder Disease 


Diet: milk, cereals and vegetables form 
a good standard. Where the liver is dam- 
aged a low nitrogenous diet is important 
so as not to throw more strain on it. In 
cases that tolerate olive oil, it should be 
given night and morning. Nearly every 
physician has had patients to whom sur- 
gery was advised, come in and tell him 
that they have been cured by the use of 
olive oil. In cases where stones exist stim- 
ulation of the flow may bring on an attack 
of gall stone colic, and many cases will 
have to go on very careful diet, avoiding 
rich, greasy foods, fried foods, tripe, sweet 
breads, crab meat, lobster, pork and sau- 
sage. Regular meals are important as 
this tends to empty the tract and prevent 
stasis. 

Rest: Strenuous work or play aggra- 
vates the condition and may bring on an 
attack. The patient should lead an easy 
even life and avoid worry. 

Drugs: Hexamethylenamine, saline ca- 

thartics and olive oil as previously 
stated constitute the fundamental arma- 
mentarium. 

Drainage by means of duodenal lavage 
with some stimulant as magnesium sul- 
phate, which is the strongest and is used 
in 33 percent solution or with olive oil, 
sodium sulphate, peptones, dilute hydro- 
chloric acid, etc., followed by transduo- 
denal flushing with Ringer’s solution, as 
recommended by Lyons, is good. This may 
be done daily to weekly to begin with and 
the periods lengthened as improvement 
occurs. The patient may carry on the 
drainages occasionally after discharge from 
active treatment. In certain cases the 
drainages may be continuous and Lyons 
states that these cases should be hospital- 
ized, the duration of the drainage being 
from ten days to two weeks. 

Vaccines: Autogenous vaccines are rec- 
ommended highly by some men where a 
definite infection can be demonstrated. 

In the last group of cases in which com- 
plications have developed, surgery is indi- 


cated. Cases in which stones are present 
are definitely surgical as it is impossible 
to remove them medically unless they are 
very small and records show that there is 
a higher cancer incidence in gall bladders 
that contain stones. Many of these cases 
will have to be treated medically after re- 
moval of the lesion as there is always more 
or less perihepatitis, choledochitis and even 
cholangitis present which must be cleared 
up if good results are to be constant. 

Medical treatment is indicated in the 
following conditions: Early gall bladder 
and duct catarrh; simple catarrhal jaun- 
dice; in hepatic intestinal toxemias with 
dizziness, headaches, nervous indigestion, 
belching, biliousness, anorexia and malaise; 
military migraine; associated with other 
treatment in obstinate neuritis and rheu- 
matism; acute cholecystitis, choledochitis 
and cholangitis; old people or patients in 
whom heart or kidneys contraindicate 
surgery; patients who refuse operation; in 
relapsing cholangitis after cholecystectomy, 
it may save a second operation; in persis- 
tent fistula following operation ; in obstruc- 
tive jaundice, together with morphin, may 
let the stone bob back or even pass and 
better the operative risk by clearing the 
jaundice; restless cholelithiasis with in- 
flammation of the mucus membrane to 
quiet down and improve the operative 
risk ; post-operative hiccough and adynamic 
ileus; early cirrhosis of the liver; typhoid 
carriers. 

SUMMARY. 

1. Medical treatment is indicated in all 
infections of the biliary tract. Complica- 
tions are not infections, but the results of 
the infection, and are surgical. 

2. Diagnosis must be made as early as 
possible. 

3. Medical treatment must not be car- 
ried on past the stage where surgery will 
aid. 

4. Medical treatment is an aid to sur- 
gery pre-operatively and post-operatively. 


Bessesen— Medical Therapy of GaU Bladder Disease 


209 


BIBLIOGRAPHY. 

Bain, William: The diagnosis and treatment of early 

cases of subacute cholecystitis. Practitioner, 113:358, 

1924. 

Blalock, Alfred : A statistical study of 888 cases of 

biliary tract disease. Bull. Johns Hopkins Hosp., 35:391, 

1924. 

Brooks, Harlow: Chronic gall bladder disease and appen- 

dicitis. M. Clin. N. Amer., 8:7-17, 1924. 

Buford, R. K. : Clinical and surgical study of fifty con- 

secutive pathologically demonstrated cases of gall bladder 
disease. W. Virginia M. J., 16:419, 1922. 

Chanffberlain, L. G. : When a diseased gall bladder be- 

comes surgical. New Orleans M. & S. J., 75:238, 1922. 

Deal, Don, & McMeen, C. V. : The diagnosis and treat- 

ment of peptic ulcers and gall bladder diseases. Illinois 
M. J., 42:261, 1922. 

Eusterman, G. B. : Disease of the gall bladder in the 

young. Ann. Clin. Med., 2:283-285, 1923. 

Fisher, David, & Snell M. W. : Some difficulties in the 

diagnosis of chronic gall bladder disease. Wisconsin M. J., 
22:215, 1923. 

Graham, E. A., & Cole, W. H. : Roentgenologic exam- 

ination of the gall bladder. J. A. M. A., 82:613, 1924. 

Graham, E. A., & Cole, W. H., & Copher, G. H.: Visual- 

ization of the gall bladder by the sodium salt of tetra- 
bromphenolphthalein. J. A. M. A., 82:1777, 1924. 

Hale, Kelley : The present status of gall bladder and 

pancreatic disease as it pertains to etiology, diagnosis and 
treatment. Ohio State M. J., 18:665, 1922. 

Hartman, H. R. : Diseases of the biliary system. Ann. 

Clin. Med., 1:107-116. 1922. 

Jenkins, W. A. : The treatment of gall bladder infections : 

Is there is a medical treatment? Kentucky M. J., 23:143-49, 

1925. 

Jones, C. M. : The rational use of duodenal drainage. 

Arch. Int. Med., 34:60, 1924. 

Joyce, T. M. : Cholangitis and cholecystitis. S. CUn. N. 

Amer., 4:1333, 1924. 


Kellogg, E. L. : Gall bladder disease in childhood. Ann. 

Surg., 77:587, 1923. 

Lutz, J. R. : The Bassler pancreatic efficiency test in 

chronic cholecystitis. M. J. & Rec., 123:719-720, 1926. 

Lyon, B. B. V.: The value of drainage of biliary tract. 

M. Clin. N. Amer., 8:803-819, 1924. 

McCelvey, J. S. : The diagnosis and treatment of gall 

bladder diseases. Texas State J. Med., 19:24, 1923. 

McMaster, P. D. : Do species lacking a gall bladder pos- 

sess its functional equivalent. J. Exp. Med., 35 :127-140, 
1922. 

Meland, Orvill: Results in the treatment of inflammatory 
diseases of the gall bladder and its ducts. Minnesota Med., 
6:90, 1922. 

Mentzer, S. H. : A clinical and pathologic study of cho- 

lecystitis and cholelithiasis. Surg. Gyn. Obst., 42:782-793, 

1926. 

Moore, F. D. : The associated pathology of gall bladder 

disease with a further plea for cholecystectomy. Surg. 
Gyn. Obst., 35:338, 1922. 

Rankin, F. W., & Massie, F. M.: Primary tuberculosis 

of the gall bladder. Ann. Surg., 83:782, 1926. 

Sachs, A., & Howard, M. C. : Lyon-Meltzer gall bladder 

drainage. Nebraska M. J., 6:225, 1921. 

Sachs, A., Howard, M. C., & Barry, M. W. : Medical bil- 

iary drainage. Am. J. Med. Sc., 167:368, 1924. 

Silverman, D. N. : Observations of the visualized gall 

bladder by the Graham method. J. A. M. A., 84:416, 1926. 

Starr, F. N. G. : Lessons learned from a study of the 

gall bladder. Canad. M. A. J., 12:85, 1922. 

Synnott, M. J. : The diagnostic and therapeutic value of 

Lyon’s method of non-surgical duodeno-biliary drainage. 
Am. J. Surg., 36:136-140, 1922. 

Whipple, A. O. : Surgical criteria for cholecystectomy. 

Am. J. Surg., 40:129-131, 1926. 

Wilensky, W. O. : The diagnosis and treatment of gall 

bladder disease. New York M. J., 114:295, 1921. 

Wilkie, D. P, D. : Biliary infections with special refer- 

ence to diagnosis. Brit. M. J., 2:163, 1924. 


CASE REPORTS AND CLINICAL SUGGESTIONS 


PAPILLARY CYSTADENOMA OF THE 
BREAST. 

REPORT OF A CASE. 

R. C. HILL, M. D., 

Bellamy, Ala. 

Papillary cystadenoma of the breast is 
one of the rare tumors, a large number of 
which undergo malignant degeneration. 
There is so little to be found in the litera- 
ture on the subject that the report of a case 
may be of interest. 

Case Report: A negro woman, aged 48 years, 

married, was admitted to the Bellamy Hospital, 
Nov. 13, 1927. One sister had died at the age of 


44 years of cancer of the womb. The patient is 
the mother of five children, all of whom were 
breast fed. 

iShe first noticed a lump the size of a marble 
in the right breast during November, 1926. This 
had gradually grown to the size of an orange at 
the time of the operation. It was never painful, 
nor was there any discharge from the nipple. 
She was well developed, fairly well nourished, 
though she claimed to have lost 50 pounds in the 
past year. There was a cardiac systolic murmur 
heard best over the apex. There was a mass in 
the right breast about the size of an orange 
located in the upper outer quadrant, freely mov- 
able, not attached to the skin, smooth outline on 
palpation, neither hard nor fluctuating, and with 
no discharge from the nipple. The axillary 


210 


Case Reports and Clinical Suggestions. 


glands were not palpable. The urine contained 
albumin. The Wassermann reaction was positive. 

A radical amputation of the right breast was 
done Nov. 14, 1927. The axillary space was not 
thoroughly dissected out because of the poor con- 
dition of the patient during operation. She was 
discharged Nov. 30, to return for dressings and 
antisyphilitic treatment. She was last seen Dec. 
21, 1927. The wound was healed at that time, 
and the patient apparently fully recovered from 
the operation. 

Gross examination of the tumor showed a mul- 
tilocular cyst filled with bloody fluid. It con- 
tained a large amount of papillomatous growth 
with multiple attachments to the cyst wall. At 
the base of the cyst, the growth had infiltrated the 
surrounding tissue. 

Historical: Strasser^) in his article 

gives a very complete history. He con- 
siders some of the cases which Astley 
described in 1829 as hydatid diseases of 
the breast, were in fact papillary cysta- 
denomas. Brodin described the condition 
in 1840 but confused it with involution 
cysts, as did Birkett. Rougeau, in 1874, 
considered it a variety of retention cysts. 
Butlin thought epithelial irritation caused 
the intracystic growth. 

Gross, writing in 11880, included them in 
the class of adenomas. Bowlby was the 
first to use the term duct papilloma, in 
1888, but Strasser thinks he confused 
benign and malignant forms of similar 
conditions. Virchow, Basse, Schimmelbush, 
and Trietze called it either cystadenoma 
papillari, intracanalicular cystadenoma, or 
papillary cystoma, but considered the con- 
dition only a developmental phase of invo- 
lution cysts and malignant degenerations. 
111*2) reported cases in 1905. Warren*®^ in 
1905 did much to settle the classification, 
and since then the condition has been 

recognized as a distinct clinical entity. 
Greenough and Simmons*^> in 1907, Blood- 
good*^> in 1908, Speese<®> in 1908, Erd- 

man*’^> in 1912, Upcott*®^ in 1913 have 

written on the subject and reported cases. 

Etiology: Neither trauma, mastitis, 

lactation, marriage, nor celibacy seem to 
have any definite bearing. However, most 
of Erdman’s patients were married women 


without children. These tumors appear 
most often after the menopause, and at the 
average age of 50 years. Yet they may 
occur in the very young and in the old. 

Histology: These cysts of the breast 

with intracystic papillomatous growths are 
usually single, but may be multiple, and 
even bilateral. They may be unilocular or 
multilocular. The papillomatous growth 
is attached to some segment of the cyst 
wall and may consist of only one papilla, 
or it may fill the cyst. There are often 
many points of fusion with the wall. The 
epithelium of the cyst is the same type as 
that of the lactiferous ducts, and is an out- 
growth from some duct. The cysts are 
filled with a bloody serum, or, in an occa- 
sional case, a chocolate colored fluid. This 
serum usually escapes from the nipple, or 
may be expressed by manipulation. Should 
the duct be occluded, this characteristic 
feature is absent. The cyst may adhere to 
the skin in rare cases, and even open ex- 
ternally. These tumors tend to undergo 
malignant degeneration in about 50 per 
cent of the cases. The structure of the 
malignant growth is the adenocarcinoma- 
tous type. It is one of the least malignant 
and invades the lymph system only after a 
long time. 

Clinical Diagnosis: This almost depends 
upon the presence of this bloody discharge 
from the nipple. Cancers, however, in 
some few cases show such a discharge, as 
do involution cysts also. Involution cysts 
are more diffuse, nodular, and more often 
are on the periphery of the glands. Papil- 
lary cystadenomas are usually situated 
near the nipple, ordinarily have no skin 
attachments, and are freely movable. They 
are not painful. These cysts may enlarge 
during pregnancy and lactation and secrete 
milk. Then they can be mistaken for 
malignancies or galactoceles. The presence 
or absence of palpable axillary glands 
should not influence the diagnosis, as they 
may be present in benign conditions and 
absent in cancers. 


Case Reports and Clinical Suggestions. 


211 


Treatment: The injection method of 
treatment has been discarded as it some 
times stimulates their growth. The recog- 
nized treatment is excision of the tumor 
or of the breast, and in case of infiltration 
through the cyst wall, the radical operation. 
Since exact diagnosis cannot be made with- 
out incision, many surgeons prefer to 
make an incision into the tumor at the 
time of operation, then to proceed accord- 
ing to their findings, either to simple ex- 
cision of the breast, or radical amputation. 

Upcott<®) says if on cutting into it gran- 
ular material is found instead of the 
usual bloody fluid; if the cyst is occupied 
by a nodular growth instead of a soft 
friable papilloma; or if there is much in- 
filtration of the wall of the cyst at the 
base of the papilloma ; or if there are many 
small dilatations filled with epithelial 
growth and blood, we can diagnose cancer 
and proceed accordingly. If there are 
none of these signs, it is well to remove 
the whole breast, for even local resection 
will cause the loss of the nipple. 

Comment: Papillary cystadenomas, 

though rare, are important because so 
large a proportion become malignant. 
They grow so slowly that early treatment 
offers an excellent chance of cure. This 
paper a4ds another case to the number 
reported. 

BIBLIOGRAPHY. 

1. Strasser, August A.: Duct papilloma: papillary cys- 

tad'enoma of breast. J. M. Soc. New Jersey, 6:619, 1909. 

2. 111. Edward J. : Papillary cystadenoma of the breast. 

Am. J. Obst., 62:709, 1905. 

3. Warren, J. Collins : The surgeon and the pathologist. 

J. A. M. A., 45:149, 1905. 

4. Greenough, Robt. B., & Simmons, Channing C. : Pa- 

pillary cystadenoma of the breast. Ann. Surg., 45 :188, 1907. 

5. Bloodgood, Joseph C. : The clinical and pathological 

differential diagnosis of diseases of the female breast. Am. 
Jour. Med. Sc., 135:157, 1908. 

6. Speese, John: Carcinomatous degeneration of breast 

cysts. New York Med. Jour., 87:357, 1908. 

7. Erdman, John F. : Intracanalicular papilloma of the 

breast. Am. Jour. Surg.. 26:208, 1912. 

8. Upcott, Harold: Cystic mammary tumors. The Prac- 

titioner, 91:14, 1913. 


EXTRA-GENITAL CHANCRE OF THE 
UMBILICUS. 

M. WOLF, M. D., 

New Orleans 

This case is one of extra-genital chancre, 
which I thought might be of interest be- 
cause of the location of the lesion. In re- 
viewing the literature I can find but four- 
teen similar cases reported, those by Cul- 
len in Diseases of the Umbilicus. 

This is the case of a negro boy who was 
treated at Touro last April. At that time 
a diagnosis of granuloma was made be- 
cause of the character of the lesions at the 
junction of the penis and the abdominal 
wall, and bubo in the left groin. Scrapings 
were examined for Donovan bodies with 
negative findings. The Wassermann was 
negative. He was given tartar emetic 
from the fifteenth of April until the middle 
of July, without any benefit. No record 
was made of the scrapings from lesions 
sent to the laboratory for examination for 
treponema. On the twenty-third of Au- 
gust he was greatly improved. 

When I saw him, November 10, he had a 
partially healed lesion at the corona and a 
completely healed lesion at the base of the 
shaft of the penis. I was checking uj) 
cases of granuloma to discuss at the South- 
ern Medical Association meeting. At that 
time I did not think that the man had a 
granuloma. His lesions had healed except 
at the corona. He said that he had de- 
rived more relief from the six doses of 
salvarsan during August and September 
than from any previous medication. He 
came in on November 22 and a Wasser- 
mann was done by one of the members of 
the Staff and found negative. I saw him 
again November 26, and he complained to 
me of having a sore in the umbilicus. 
Examination showed the lesion on the 
corona almost healed. There was edema 
and induration around the umbilicus with 
a granulating ulcer in the umbilical fossa. 
Scrapings from the umbilical sore showed 
treponema pallida, the partially healed sore 


212 


Case Reports and Clinical Suggestions. 


on the corona was absolutely negative for 
Donovan bodies and treponema. He was 
to get arsphenamine and I have no record 
since second course of treatment was 
started. 

Cullen reported first a case of Bloom’s 
(1876), unquestionably syphilis; he also 
reported twelve cases in 1912 and three 
cases in 11914. Fischer, of Sydney, Austra- 
lia, in a personal communication to Cullen 
cited one case in which a man had a chan- 
cre of the penis and a chancre of the 
umbilicus. Cullen cites Fournier, who. 


working on 10, 900 cases of chancre, found 
sixteen umbilical lesions. 

A point of interest in this case is that 
the patient had arsphenamine several 
weeks before the lesion appeared at the 
umbilicus, and the lesion on the penis had 
not completely healed with arsphenamine. 

Note: Since making the above report 

patient has been given more treatment 
with arsphenamine and the lesions were 
completely healed after the second dose, 
ten days after treatment was resumed. 


NATIONAL LEPER HOME AT CARVILLE.— 

Surgeon General H. S. Gumming has recently sub- 
mitted to Congress an interesting report relating 
to the National Leper Home, located at Carville, 
La. During the past year 56 lepers were ad- 
mitted to this hospital; 12 were readmitted and 
2 patients were discharged on parole, as their 
leprosy was arrested and considered no longer a 
menace to public health. Seventeen deaths oc- 
curred during the year at this hospital. 

The nativity of the patients in the National 
Leper Home is of interest. They come from 20 
States and 3 of the insular possessions of ' the 
United States. Persons are also patients in the 
hospital from 24 foreign countries. Louisiana, 
Florida and Texas lead the States furnishing 
patients to the National Leper Home. At present 
278 patients are under treatment in the Home. 
Practically all of these patients are receiving 
chaulmoogra oil, which is the drug that seems to 
be most beneficial in the treatment of leprosy. It 
is administered in some cases by mouth in doses 
ranging from 3 drops to 300 drops daily. Some 
of the patients receive intramuscular injections of 
this oil. 


Leprosy does not respect race, creed or social 
status. A leprosarium for patients from a large 
country cares for a cosmopolitan gl-oup seldom 
encountered in a general hospital. The manifold 
manifestations of leprosy, with the diversity of 
symptoms and the variety of psychologic responses 
coupled with the conscious or unconscious pessim- 
ims of the average human being suffering from a 
chronic progressive disease, confront the medical 
officers of this institution with the difficult prob- 
lem of maintaining a proper morale. Recogniz- 
ing the great importance of occupation to prevent 
morbid introspection, paid employment is offered 
patients physically and mentally fit to work at 
light tasks, to the profit of both patients and 
hospital. During the current year, on an average 
of 81 lepers have been thus employed at the hos- 
pital, the assignments ranging in variety from 
the more simple duties of housekeeping and bed- 
side care of fellow-patients to the more exacting 
work as assistants in the general laboratory, 
physiotherapy department, dental laboratory and 
operating rooms. Daily routine occupation is 
there supplied to one-third of the total population 
of the hospital and to almost all of those physi- 
cally fit for such an undertaking. — Bull. U. S. 
Pub. Health Service, April 23, 1928. 


Editorials. 


213 


NEW ORLEANS 

Medical and Surgical Journal 

Established 184-4. 

Published by the Louisiana State Medical So- 
ciety under the jurisdiction of the following named 
Journal Committee : 

L. J. Menville, Ex-Officio 
For three years, H. W. Kostmayer, M. D., 
Secretary, S. M. Blachshear, M. D. 

For two years, H. B. Gessner, M. D., Chairman 
For one year, Paul J. Gelpi, M. D., Lucien 
Ledoux, M. D. 

EDITORIAL STAFF 


John H. Musser, M. D - Editor 

H. Theodore Simon, M. D Associate Editor 

J. S. Ullman, M. D..... Associate Editor 

Williard R. Wirth, M. D Associate Editor 

Frank L. Loria, M. D -..Associate Editor 


COLLABORATORS— COUNCILLORS 


For Louisiana 
H. E. Bernadas, M. D. 
Urban Maes, M. D. 

C. C. DeGravelles, M. D. 
S. C. Barrow, M. D. 

D. I. Hirsch, M. D. 

A. G. Maylie, M. D. 

D. C. lies, M. D. 

G. M. C. Stafford, M. D. 


For Mississippi 
J. W. Lucas, M. D. 

J. S. Donaldson, M. D. 
M. W. Robertson, M.D. 
T. W. Holmes, M. D. 

D. W. Jones, M. D. 
W. G. Gill, M. D. 

E. M. Gavin, M. D. 

J. W. D. Dicks, M. D. 
D. J. Williams, M. D. 


Paul T. Talbot, M. D General Manager 

1551 Canal St. 

SUBSCRIPTION TERMS: $3.00 per year in 

advance, postage paid, for the United States; $3.50 
per year for all foreign Countries belonging to the 
Postal Union. 

News material for publication should be received 
not later than the twentieth of the month preced- 
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in duplicate when returning galley proof. 

The Journal does not hold itself responsible 
for statements made by any contributor. 

Manuscripts should be addressed to the Editor, 
1551 Canal St., New Orleans, La. 


in the United States. The nervous and 
mental hospitals in the state number 5 with 
a capacity of 4,249 and having 3,860 
patients. In addition to these general hos- 
pitals there are a total of 67 registered 
hospitals with 11,208 beds and 8,255 
patients. In the state of Mississippi there 
are 58 general hospitals with a bed 
capacity of 3,025 and an average number 
of patients in these beds 1,584. In Missis- 
sippi the nervous and mental hospitals are 
3 in number with a capacity of 3,237 with 
virtually all places filled. For the care of 
the tuberculous, Louisiana has 5 hospitals, 
with 632 beds with an average of only 317 
patients. Mississippi has 2 such hospitals 
with 524 t>eds, 325 of which are occupied 
on the average. Mississippi has a total 
number of 70 registered hospitals, a ca- 
pacity of 7,062 and an average census of 
5,175. 

This report of hospital service will prove 
of great value for ready reference in order 
to determine the size and number of the 
hospitals throughout any state, the type of 
service rendered by a particular institution, 
whether the hospitals are approved for in- 
ternship training, whether they have a 
nurses training school, and such general 
information. It gives practically all the 
data and facts about hospitals which one 
would be called upon to use ordinarily. 


HOSPITAL SERVICE IN THE UNITED 
STATES. 

A recent number of the official organ of 
the American Medical Association has just 
published a special hospital number detail- 
ing much information concerning hospitals 
in the United States. The facts are com- 
piled from a census of hospitals taken in 
the last few weeks and are not obtainable 
elsewhere. Perusing the report it is noted 
that in Louisiana there are forty-two gen- 
eral hospital with a capacity of 5,155 beds, 
having an average of 3,430 patients. The 
percentage of occupancy is 66.5 as com- 
pared with 66 per cent in general hospitals 


PERCUSSION OF THE HEART 
BORDERS. 

There has always bten considerable 
doubt in the minds of clinicians and 
students as to the accuracy and value of the 
determination of the size of the heart by 
percussion. Admitting that percussion is 
the most difficult of the methods of physical 
diagnosis to master, and that confidence and 
accuracy are attained only after consider- 
able experience, the question still remains 
as to the actual comparison between the 
area of cardiac dullness and the size of the 
heart as determined by our most accurate 
clinical method, the Roentgen ray. Kurtz 


214 


Editorials. 


and White* have made a study of one hun- 
dred patients of all ages and both sexes, 
comparing the results obtained by percus- 
sion with those obtained by the use of the 
roentgenogram taken at a distance of 7 
feet. Three different observers made the 
percussion observations, a fourth individual 
determining the roentgen ray findings. The 
observations were apparently well con- 
ducted and they are certainly interesting. 
For example, the average “error” in the 
percussion of the left border of dullness at 
the apex varied from 0.2 to 1.5 cm., aver- 
aging about 0.6 cm. It was noted also that 
the area of supracardiac dullness in the 
second space, measured from right to left, 
was narrower than the width of the great 
vessels as shown in the roentgenbgrams in 
88 of 97 cases. This was considered the 
most difficult measurement to obtain by 
percussion, and is usually inaccurate unless 
the widening is rather marked. 

The authors conclude that percussion is 
of value and is reasonably accurate. The 
border of dullness was taken as being most 
accurate not at the point of the first change 
in note but where the dullness is first 
definite. Certainly considerable emphasis 
must be placed upon the technic of percus- 
sion. The authors think that cardiac en- 
largement can be determined with a fair 
degree of accuracy for all practical clini- 
cal purposes by considering whether or not 
the left border of dullness lies outside the 
midclavicular line, in which case the heart 
may be considered enlarged. This study 
confirmed this view and 78 per cent of the 
cases showing signs of pathology extended 
past the midclavicular line. 

Considering the applicability of percus- 
sion to all cases and the reasons prohibit- 
ing the routine use of the Roentgen ray 
the study strengthens our confidence in the 
accuracy of this readily available method 
of determining heart size. Certainly it 
would be of decided advantage to check 
our percussion results occasionally with 

*Kurtz, Chester M., and White, Paal D'.; Am, 
Jour. Med. Sc., 176:181-195, 1928. 


the more accurate method, so endeavoring 
in this and every other manner to perfect 
our percussion technic which is to a large 
extent to determine the reliability of the 
findings. 


PHYSICIANS IN THE EMPLOYMENT 
OF THE UNITED STATES 
GOVERNMENT. 

Some very interesting information is 
presented in a recent bulletin of the United 
States Civil Service Commission. It shows 
very definitely, through the mind of an un- 
prejudiced reader, that there should be 
some central control of the medical service 
provided by the United States. In addition 
to the three larger services of the Navy, 
the Army, the Public Health, all under 
different departments, we find the follow- 
ing disposition of physicians in the Gov- 
ernmental service. In the Department of 
Agriculture, four are employed, whose sole 
duty is to interpret the truthfulness or 
falsity of statements on medical labels. In 
the Department of Commerce, two physi- 
cians are detailed to Pribilof Islands, 
Behring Sea, six are assigned to the coast 
survey service, including Alaska and 
Hawaii, while the sole physician assigned 
to this service in the Philippines has to 
take care of the health of the crew. When 
the health of the crew is excellent he has 
to fall to and help out in the surveying 
operations. In the Department of the In- 
terior, eight are on all year around detail 
in Alaska, three are in the Freedman’s 
Hospital, and forty in St. Elizabeth’s hos- 
pital. There are 125 full time physicians 
and 65 contract physicians who have care 
of the health of the Indian wards of the 
nation. The Pension Claims Department 
employs 15 doctors. The Department of 
Labor is satisfied to get by with 10 doc- 
tors, three of whom are in the Child Hy- 
giene Division and seven in the Maternity 
and Infancy Division. The Treasury De- 
partment employs 350 full time medical 
officers, with the rank of Acting Assistant 
Surgeon, not commissioned in the Public 


Editorials. 


215 


Health Service, while one hundred and 
fifty are on part time. The Veterans’ Bu- 
reau has the largest number of physicians 
in any division, twelve hundred receiving 
pay from the Government. In the Pan- 
ama Canal Zone, 28 men are employed in 
dispensary and quarantine work in addi- 
tion to those in the Public Health, Army 
and Navy services. Certain divisions of the 
Government not under main departments 
also employ a few physicians; thus there 
are two in the Government Printing Office ; 
one in the Bureau of Engineering; one is 
doing relief service, and one is giving his 
service to the Civil Service Commission. 

In addition to the definite impression 
that all these medical services should be 
under one head, one is also struck by the 
variegated and widely dispersed duties of 
these medical men. Contrast the life of 
the two physicians assigned to the Pribilof 
Islands, or the eight in the Alaskan medi- 
cal service, and the 125 in the Indian ser- 
vice with its strenuous activity, and physi- 
cally exhausting demands with the peace- 


THE IMPORTANCE OF RESPIRATORY DISEASES AS A 
CAUSE OF DISABILITY ANONG INDUSTRIAL WORK- 
ERS. — A large electric light and power company, which 
pays full wages to its employees who are disabled by sick- 
ness, keeps a record of the diseases which cause time lost 
from work. The company asked the United States Public 
Health Service to co-operate in the analysis of this record. 
When the tabulations were completed, it was found that 
more than one-half of all the absences on account of sick- 
ness among the men in the employ of the company was 
caused by diseases of the respiratory system, the more 
common of which are the ordinary cold, sore throat, tonsi- 
litis. bronchitis, influenza or grippe, and pneumonia. This 
record is of especial interest, because it includes all ab- 
sences lasting one day or longer during a ten-year period. 

As a cause of absence from work among employees of 
this company, no other disease group approached in im- 
portance the respiratory diseases. In fact ,the respiratory 
diseases caused more absences than all other diseases com- 
bined. It is not unreasonable to suppose that this sickness 
experience is more or less representative of the experience 
of other groups of employed persons. 

The records of employee benefit associations scattered 
over the northern and eastern part of the United States 


ful and quiet existence of the 40 physicians 
who are in St. Elizabeth’s Hospital, or the 
four labratorians in the Department of 
Agriculture, or the seven men in the 
Maternity and Infancy Division. It makes 
one appreciate more than one usually gives 
thought to the matter, in looking over the 
list of doctors employed by the United 
States how far flung is this United States, 
and how many activities the Federal Gov- 
ernment undertakes. 


INTERSTATE POSTGRADUATE 
ASSOCIATION. 

The Interstate Postgraduate Medical As- 
sociation of North America will meet in 
Atlanta, Georgia, this year, from October 
12 to October 19. The preliminary pro- 
gram includes the names of medical men 
of national and international reputation. 
These meetings are always well worth while, 
and certainly this meeting in Atlanta pre- 
sents a wonderful opportunity close at hand. 


tell much the same story. From the recorded experience of 
36 different sick-benefit associations having a combined mem- 
bership of nearly 100,000 persons, it was found that respira- 
tory diseases caused 47 per cent of all the cases of illness 
for which sick-benefits were paid from 1921 to 1926, inclu- 
sive. This source of information covers only the more 
serious sicknesses, because these associations made pay- 
ments to their members only when illness caused inability 
to work for 8 days or longer. 

Thus, whether we consider all absences from work on 
account of sickness, or only those illnesses which lasted 
longer than one week, we find that approximately one-half 
of the cases were some form of respiratory sickness. Ap- 
parently, man’s breathing apparatus is especially liable to 
microbic attack. With this evidence that the organs of 
respiration are particularly vulnerable, it is apparent that 
we ought to take special precautions against respiratory 
infection. 

The sickness records of the electric light and power com- 
pany showed, also, that the average loss of time on account 
of sickness was approximately six days a year per man on 
the payroll. Approximately three of the six days lost from 
work per annum were lost on account of respiratory dis- 
eases. — Bull. U. S. Pub. Health Service, April 19, 1928. 


HOSPITAL STAFF TRANSACTIONS 


TRANSACTIONS OF STAFF OF SOUTHERN 
BAPTIST HOSPITAL. 

Dr. L. R. DeBuys presented a case of Baby R„ 
born 9/19/27, and seen in hospital in September. 
The child presented several interesting features. 
It was not an extremely rare condition, but one 
that we come across in the newly-born — a case of 
hemorrhagic disease of the newly-born. This case 
had been referred to him by Dr. Phillips, who de- 
livered the mother with forceps. The child showed, 
the first day, an ecchymotic spot under the right 
eye which was looked upon as a traumatic origin. 
On the second day, the baby became ill and vom- 
ited blood. He was then asked to see it. On 
examination, the original ecchymotic spot under 
the right eye was noted as well as two ecchymotic 
areas over the lower part of the chest, and also 
similar spots behind the elbows where they had 
been resting on the mattress, and another spot on 
the buttocks. She was considerably dehydrated 
with the fontanels much depressed and overlap- 
ping of the sutures. Physical examination was 
negative, with the exception of the liver, which 
extended below the costal border about one inch, 
and the spleen, about one-quarter of an inch below 
the costal border. Examination of the mouth 
showed the presence of thrush. The refiexes were 
all negative. There were no focal symptoms and 
there was apparently no evidence of any hemor- 
rhage involving the nervous system. There was 
great difficulty in breathing and an inability to 
swallow. The temperature was 101.5° F. The 
birth weight, which was reported to have been 6 
lbs. 14% ozs., when first seen by him, was 6 lbs. 
7 ozs. The infant was considered to be desper- 
ately ill. The stools showed blood macroscopi- 
cally. The condition was apparently one of 
hemorrhagic disease of the newly-bom. The blood 
count showed total red blood cells — 2,780,000; 
white blood cells — S,500; platelets, 61,000, and a 
differential count of small lymphocytes, 50 per 
cent; large mononuclears, 18 per cent; polymor- 
phonuclears, 32 per cent. There were present, 
normblasts and megaloblasts, and poikolocytosis 
and anisocytosis existed. The bleeding time was 
20 minutes and the coagulation time, two minutes. 
The baby was immediately placed in the incubator 
at a temperature of 95°F. lOcc. of whole blood 
was given intramuscularly at eight hour intervals. 
Adrenalin, one minim, by needle every four hours. 
5 grains of calcium lactate was given every four 
hours. Oxygen was administered continuously, 
180 bubbles per minute. 1 per cent gentian violet 
was applied to. mouth twice daily for the thrush. 
Nasal feeding every four hours was instituted, 50 
per cent mother’s milk being administered, the 
milk being expressed from, the mother by the Abt 
breast milker. Instructions were given for no 


bath and no handling. Because of the vomiting 
of blood, rather than cause any trauma, feeding 
was accomplished through the nasal tube, the tube 
being introduced and allowed to remain in place 
there, being secured with adhesive. This tube was 
occasionally changed from one side to another 
because it was thought that it might cause some 
irritation. The second day the coagulation time 
had been reduced to 2 % minutes and the bleeding 
time to 3% minutes. The urine showed nothing 
of any moment. The baby’s condition remained 
more or less stationary until September 23, 1927, 
when she showed some improvement. September 
24, 1927, slight vaginal hemorrhage was noted. 
September 25, 1927, Ceanothin was given. After 
September 26th there was no more hemorrhage, 
and there was no more bloody nasal discharge. 
The intramuscular injections of blood were given 
until October 2nd, namely, for a period of about 
twelve days. The tube feedings, which had been 
gradually discontinued, were entirely supplanted 
by the use of the Beck feeder, no further tube 
feedings being given after October 2nd. The 
baby was discharged from the hospital on October 
14th, at which time the total red blood cells had 
gone up to 3,960,000; hemoglobin, 90 per cent; 
coagulation time, 2 minutes; bleeding time of 5 
minutes, and the differential count practically 
normal. During the time the child was in the in- 
stitution there were two rises in temperature last- 
ing three and four days respectively. The condi- 
tion responded very nicely to the intramuscular 
injections of blood. The advantage of giving the 
blood intramuscularly is that it can be done 
promptly, there being no necessity for waiting for 
typing and so on, and the effects are extremely 
good. In some of the more severe cases where 
there is sluggish response to the intramuscular 
injections, he has used the blood intraperitoneally. 
At the time that this case was here, he had another 
one at the Touro Infirmary which required intra- 
peritoneal injections besides the other measures 
adopted in this case. Three injections of the 
whole blood which had been typed were given in 
the following quantities: 60 cc., 45 cc. and 45 cc. 
In cases of this type, the urine as well as the 
stools should be watched for evidence of hemor- 
rhage. When it is necessary to resort to frequent 
intramuscular injections of blood, the injections 
should be gradually diminished in frequency and 
then in quantity. The baby should not be handled. 

Dr. Alton Ochsner chose for his subject a recent 
case of a patient who was admitted to the hospital, 
giving a history of having been hit by a truck. 
She was comatose when she came in, being roused 
with difficulty. There was some difficulty in ob- 
taining a history, because for several years she 
had been having attacks of epilepsy. Whether she 


Hospital Staff Transactions 


217 


had an attack when hit by the truck, or not, was 
not known. At no time, was there evidence of 
any shock. Roentgen-ray pictures were taken in 
the admitting room and Roentgen-ray plates 
showed a depressed fracture in the paritetal 
region extending backward. Spinal puncture 
readings were 18 mm. mercury wdth some blood. 
Because of the depressed fracture, it was decided 
to elevate the bone. This was done on the day 
she was admitted, but she was treated by dehy- 
dration, being given glucose intravenously. On 
the following day, a craniotomy was done; The 
depression was found not to be very marked, the 
outer table being depressed very slightly. On 
opening the skull, however, it was found that we 
were dealing with a large hematoma. This was 
evacuated. The dura was opened and nothing 
was found. The depression was released and the 
patient sent back to the ward. She was treated 
post-operatively with hypertonic glucose, 50 ccs 
being given immediately after being returned to 
the ward, and six hours later. The following 
morning her condition was very much better. She 
felt fairly well and wanted something to eat. 
During the first day, the condition remained un- 
eventful. On the evening of the second day she was 
again somnolent and gave very few answers. We 
thought we were dealing with the reappearance 
of the cerebral edema, and physical examination 
showed hsrperflexion on the side of the body oppo- 
site the hematoma. I suggested to the interne 
that more hypertonic glucose be given intraven- 
ously and magnesium sulphate by rectum. Before 
this was done, however, another spinal puncture 
was done. Much to our surprise, instead of get- 
ting a manometric reading of 8-10 mms. of mer- 
cury, we were only able to get 1 mm. of mercury. 
There existed a hypotension of the cerebro-spinal 
fluid. Had we gone ahead and given the patient a 
hypertonic solution and attempted to dehydrate 
her, she probably would have been killed. We 
gave her 30 ccs. of distilled water intravenously, 
and within thirty minutes, the patient was well. 

Dr. Ochsner then showed a slide which was made 
by Dr. Mims Gage, who marked out a way of 
teaching it to the students so that it is something 
to grasp. It gives an idea of the relationship of 
the various factors which we have. One thing 
should be emphasized: too much dependence 
should not be placed on blood pressure and pulse. 
At a meeting of the Charity Hospital staff two 
weeks ago. Dr. Jones reported two cases of cere- 
bral injury treated by dehydration, the spinal 
fluid readings having shown over a period of time 
a marked increase of cerebro-spinal pressure, yet 
there was no increase in the blood pressure at the 
time. Manometric readings should be made early. 
The rule is, remove half the excess. Thus, if we 
have a reading of 18 mms, we have an excess of 


10. We remove until the reading is 13. The 
treatment which we have been teaching to the 
student is that when a patient is in a state of 
shock, nothing is done until the shock has been 
controlled. Following treatment of shock, spinal 
puncture is done. If there is excess pressure ac- 
cording to the manometric reading, one-half of 
excessive amount is removed and dehydration com- 
menced. We simply use glucose solution. Weed 
and McKittrick of Johns Hopkins, use hypertonic 
saline solution. Sodium chloride undoubtedly will 
relieve cerebral edema, but not without danger. 
It is possible to produce tetany as in a case we 
saw. It must be introduced extremely slowly, not 
more than 1 cc. per minute. 

The point which must be stressed is that hypo- 
tension of the cerebro-spinal fluid is rare, but 
not so rare as we might imagine. Stultz reports 
three cases. These individuals usually complain 
of headache. Two were treated by intravenous 
method, while the third was given large amounts 
of water by mouth and by duodenal drip. In 
advanced cases, it is not wise to wait because it 
is perfectly safe to give 30 ccs. of distilled water 
intravenously. Often another puncture gives an 
increased spinal fluid pressure. 

Dr. J. Holmes Smith, Jr., spoke regarding a 
condition of more or less importance, particularly 
as regards its association with anemia. Diagnosti- 
cally, it is considered essential to the diagnosis of 
pernicious anaemia. The condition is known as 
achylia gastrica. This term really implies an 
absence, not only of hydrochloric acid, but of all 
gastric secretion. At the present time it is ap- 
plied, also, to those cases showing only a lack of 
hydrochloric acid. 

Achylia gastrica, in most instances, is prob- 
ably the result of a toxemia which gives rise to 
a gastritis and the gastritis, in turn, interfering 
with the acid-secreting cells of the stomach. This 
toxemia may result from conditions in the intes- 
tinal tract or be caused by systemic disease, such 
as syphilis and tuberculosis. 

A total absence of free hydrochloric acid, in 
the stomach, may occur in an othervdse healthy 
subject and apparently be not incompatible with 
good health. However, individuals having an 
achylia gastrica are frequently prone to gastro- 
intestinal upsets, chief of which is probably a 
tendency to attacks of diarrhea, due apparently to 
improper digestion of proteins and a too rapid 
emptying of the stomach. A more important 
result of achylia, however, is a tendency for such 
individuals to develop anemia of varying grades. 
This anemia appears to be the result of an exces- 
sive bacterial invasion of the duodenum, incident 
to the lack of acid in the gastric contents. Anemia, 
so produced, is most frequently of the secondary 


218 


Hospital Staff Transactions 


type, but a certain percentage of the cases de- 
velop into a true pernicious or hyperchromic 
anemia. 

Diagnostically, there must be a true, persistent 
achylia present, before we can assume that any 
anemia is of the pernicious type. 

It is well, at this point, to emphasize that one 
examination of the gastric contents is not suffi- 
cient for the diagnosis of achylia gastrica. The 
appearance of free hydrochloric acid in the gas- 
tric contents is sometimes quite delayed after the 
giving of a test meal. Sometimes, a simple test 
meal, such as that of Ewald, will not provoke an 
acid response, but a protein meal will. If it is 
suspected that an individual has an achylia gas- 
trica, then the first thing is to make a fractional 
gastric analysis, colecting the first sample in about 
thirty minutes and continuing to collect samples 
until two hours after giving the meal. 

If, by the fractional method, no acid is found 
in the gastric contents, we are still not justified 
in diagnosing a true achylia gastrica, because 
there may simply be a temporary suppression of 
the hydrochloric acid. This suppression of hydro- 
chloric acid or false achylia may be quite tempo- 
rary or may last for some time. 

As an aide in the diagnosis of achylia and also 
as a means of avoiding delay in diagnosis, we are 
in the habit of giving such individuals a subcu- 
taneous injection of a preparation known as his- 
tamine. Histamine is a protein derivative and has 
the property of provoking a secretion of hydro- 
chloric acid, provided the gastric cells are capable 
of functioning. 

The histamine may be given immediately after 
the fractional analysis, or at a later time. Follow- 
ing the giving of histamine, samples of gastric 
contents are secured at frequent intervals and 
examined for hydrochloric acid, as in the ordinary 
method. The appearance of acid may be very 
soon after giving the drug or it may be delayed. 
When delayed, samples should be collected for at 
least an hour and a half. 

In those cases which do not respond to hista- 
mine, we feel that a diagnosis of true achylia is 
justified. 

It should, probably, also be mentioned that his- 
tamine has the property of temporily lowering 
blood pressure and occasionally the patient will 
have symptoms such as flushing of the face, tight- 
ness in the chest, etc. In his opinion, any symp- 
tome complained of are due most likely to pro- 
tein reaction and not to lowered blood pressure. 

Dr. C. W. Allen spoke of a little patient of his 
and showed some interesting photographs of him, 
a few taken when the child was younger and 


some taken just before operation. Dr. Allen said 
that this was as bad a case of cleft palate as he 
had ever seen. The patient was operated on 
twice as an infant and the operations failed. It 
seemed impossible to do anything for him. It is 
believed that what success was had with the case 
was due to several operations and in not trying 
to do too much at one time. The child, who is now 
ten years of age, has been operated on five times, 
his lip having been closed last week. There are 
now two little holes left and the palate is not 
closed, but it was not deemed advisable to do 
anything for several months, depending upon the 
condition of the tissue which will constantly 
shrink and get down to a small point beyond 
which no closing will be desired. The first time, 
the tissue stitch came loose and the flap fell back- 
ward near the midline; the second was made 
strong and he has a very nice result. One more 
operation, the sixth, will be necessary. 


VICKSBURG SANITARIUM AND CRAWFORD 
STREET HOSPITAL. 

At the regular staff meeting, held July 11, 1928, 
the following cases were reported: 

Intra- Abdominal Hemorrhage from Rupture of 
Right Ovary. 

Dr. G. M. Street — Mrs. R. T. C., aged 23, never 
pregnant, with a past history which up to one year 
ago was negative, was seen in this clinic eight 
months ago, at which time diagnosis of cystic 
ovary with adherent retroversion was made and 
operation advised. Medication also was prescribed 
at that time for an acute digestive disorder. The 
patient returned home to prepare for necessary 
surgery, but obtained relief from symptoms and 
was not heard from again until admission to hos- 
pital on July 1. 

Ten days ago, immediately following sexual 
intercourse, was taken with severe pain in right 
lower quadrant, nausea and backache. A local 
physician prescribed, and in a few days patient 
was feeling much better. Eighteen hours before 
admission, again immediately following inter- 
course, she had the same pain in abdomen, this 
time more violent and extending across whole 
lower portion, nausea; vomiting, and followed in 
a few hours by fever of 100. 4°F. Morphine was 
required for relief. 

On admission temperature was 100. 8°F., pulse 
110, lower abdomen full with tenderness more 
acute over lower right quadrant. The slightest 
pressure on cervix or in right fornix caused acute 
pain. Leukocytes 18,400, with 92 per cent poly- 
morphonucleai’s. 

Operation: A large quantity of free blood and 
serum was in the peritoneum and the pelvis filled 


Hospital Staff Transactions 


219 


with blood clots, old and fresh. Right ovary 
showed a ruptured cyst and was actively bleeding. 
The left ovary was cystic and size of goose egg; 
the uterus was bound down in pelvis; both tubes 
sealed and distended with clear fluid (chronic 
hydrosalpinx, bilateral). 

We were confronted with a proposition which 
seemed clearly to indicate removal of both ovaries 
and tubes in an attractive young woman of 23 
years, and this we did not want to do. A small 
solid portion of the left ovary was dissected free 
of the large cyst and allowed to remain and the 
inner third of the right ovary, the most normal 
part, was dissected frae from the hemorrhagic 
portion and left in place. This seemed to be bet- 
ter than to remove both ovaries entire and then 
to do an ovarian transplant, as we were able to 
leave these portions of the ovaries with good blood 
supply. The tubes were removed, uterus fixed in 
a forward position, appendix removed, and wound 
closed without drainage. Patient has made an 
uneventful recovery. 

Surgical Pathology: Right tubes curled in cystic 
mass 2 Vz x2xl % inches, convoluted and kinked. 
Microscopic: Fibrosis; cystic distal; chronic, some 
acute inflammatory distal. 

k 

Right ovary (section) — l%xl%x% inches, 
moderately soft; filled with blood clot, exuding 
through opening % inch. Cyst size of pea on 
surface. Microscopic: Cystoma (multiple) ; much 

interstitial hemorrhage; large corpus leuteum, re- 
cent, apparently not involved in hemorrhag'e. 

Diagnosis: Appendicitis, chronic and acute; 
salpingitis, chronic, cystic, bilaterial; hemorrhage 
of ovary, right; cystoma of ovary, right. 

The object in presenting this case is to demon- 
strate the fact that a serious intro-abdominal 
hemorrhage occasionally occurs from rupture of 
the ovary. This is the third case of this type seen 
in the past three years. The first one presented 
more serious symptoms of shock than the one here 
presented. Differential diagnosis from ruptured 
tubal pregnancy is difficult. 

The case was discussed by Drs. A. Street, L. S. 
Lippincott, S. W. Johnston, L. J. Clark, and J. A. 
K. Birchett, Jr. 

Ulcer of the Duodenum with Long-Standing Chronic 
Perforation. 

Dr. A. Street — iMr. M. J. S., aged 52, a married 
man with five children, was admitted to the hos- 
pital March 19. Onset of symptoms began eight 
months ago with nausea and vomiting of huge 
quantities of fluid, not of “coffee ground" type; 
marked constipation; slight fever, not over 100°F. ; 
no pain except one night when had lower abdom- 
inal colic. Following this first attack, he lost 20 


pounds in weight. He then improved, become free 
of symptoms, and gained 25 pounds in weight. 
There was a recurrence of symptoms one week 
ago with vomiting of large quantities of fluid, 
slight fever, slight icterus, constipation and tarry 
stools, together with extreme prostration and rapid 
loss of weight. He could feel fluid splashing in 
epigastric region on shaking. 

He had had a period of suffering from hunger 
pain twenty years ago. 

Physical Examination: Temperature 100 °F.; 
blood pressure, 105/90. Extremely weak; ema- 
ciated; skin slightly yellow. Physical examination 
was not remarkable except for the abdomen which 
was slightly distended and showed visible peristal- 
sis at and slightly above level of umbilicus. Marked 
succession sounds could be elicited in epigastrium. 
Liver was enlarged to two inches below right cos^ 
tal margin; edge firm; no other masses made out. 

Blood: Hemoglobin, 34 per cent; erythrocytes, 
2,400,000; much anisocytosis, some poikilocytosis, 
slight polychromatophilia; coagulation time 2 min- 
utes; bleeding time, 30 seconds; leukocytes, 12,500; 
neutrophiles, 91 per cent. 

Gastric Contents: Brown color; chemical, blood 
-f-f-f; total acid, 39; free HCl, 36; combined 
acid, 1 ; no lactic acid ; no bile. Feces showed 
blood. 

Roentgenologic examination: Stomach is very 
large with marked gastroptosis, much of stomach 
being below the pelvic brim; otherwise not remark- 
able. Duodenal cap fills imperfectly and shows 
deformity consistent in appearance with duodenal 
ulcer. 

The patient was treated by diet and stomach 
kept fresh by daily gastric lavage for 22 days 
following admission, with slight improvement. 

Operation performed April 10. High right rec- 
tus incision. An inflammatory mass was plas- 
tered to the under surface of the liver, including 
gall bladder, upper portion of duodenum and the 
pylorus, vdth omentum densely adherent. It was 
thought inadvisable to attempt to break up this 
mass, as this could hardly be done vdthout tearing 
of structures, and furthermore it was not kno"wn 
what the mass might contain. In order to get 
information as to the condition of the stomach 
and duodenum, a vertical incision was made in the 
stomach 1 % inches proximal to the mass. A 
finger was then passed through the pylorus into 
the duodenum. A perforated ulcer was easily 
made out on the upper surface through which 
the finger easily passed into a cavity on the under 
surface of the liver, about the size of a lemon. 
The tissues did not give the impression of being 
carcinomatous. Gastro-enterostomy seemed to be 


220 


Hospital Staff Transactions 


the only posible beneficial procedure, and in order 
to facilitate matters, anterior gastro-enterostomy 
was easily and rapidly done by anastomosing the 
jejunum to the exploratory opening in the 
stomach. 

Patient’s recovery was uneventful and progress 
up to the present has been uninterrupted. 

Discussed by Dr. S. W. Johnston 

Fracture of the Os Calcis, Illustrated by Roentgeno- 
logic Studies of Four Cases. 

Dr. J. A. K. Birchett, Jr. — Fracture of os calcis 
is generally due to fall upon the foot from a 
heighth by contraction of the muscles attached to 
the tendoachilles or forcible inversion of the sole 
of the foot. The bad results are raising, shorten- 
ing and outward deviation of the heel with flatten- 
ing of the arch, fragments projecting into the 
sole, loss of motion between os calcis and astra- 
galus, and mechanical interference between os 
calcis and external malleolus. Temporizing with 
fracture of the os calcis is courting disastrous 
results. Average disability is from 12 to 18 
months in face of radical treatment, and the more 
severe cases are permanently disabled. Cotton 
found 90 per cent permanent partial disability, 
and Manguson shows a disability of 35 to 75 per 
cent. 

Discussed by Drs. A. iStreet and S. W. Johnston 
Tuberculosis of the Maxillary Sinus. 

Dr. E. H. Jones — This case is presented because 
of the rarity of the condition and the method of 
treatment. Up to 1907, only 20 cases of tuber- 
losis of the maxillary sinus had been reported in 
the literature. 

The patient, a man, aged 50, was bleeding from 
nose every day in amounts from one to four drams 


and had bled as much as an ounce in one day. He 
had pulmonary tuberculosis. 

Radical antrum operation was performed. A 
tubercle was found on a septum from the roof, 
but pathologist was unwilling to make a positive 
diagnosis of tuberclosis. After treatment by oil 
according to the Sludder method, purulent mate- 
rial from antrum showed tubercle bacilli. Treat- 
ment was then changed to chaulmoogra oil, using 
every day in five cc. amounts. Condition rapidly 
improved and after one year there is apparent 
cure. 

Discussed by Drs. A. Street, Lippincott and 
Johnston. 

Aneurism, Probably of the Arch of the Aorta. 

Dr. L. J. Clark — The patient, a negro man, 
aged 52, with pulsating mass size of orange, erod- 
ing through upper sternum, slightly to left, of 
thirty days’ duration; had been in excellent health 
previous to that time. Present symptoms are pain 
referred down left arm, shortness of breath, par- 
tial loss of voice, and slight brassy cough. 

Physical examination shows well developed and 
nourished man, with a heart markedly enlarged, 
with loud systolic murmur at apex; blood pressure 
130/60 right, 120/60 left arm. Flouroscopic ex- 
amination shows large pulsating mediastinal mass, 
about 4i/^x3x4 inches, and extending anteriorly 
through chest wall. Wassermann test -f + +- 

Discussed by Drs. Johnston, A. Street and Bir- 
chett, Jr. 

Special Report: The recent meeting of the 
American Society of Clinical Pathologists. — Dr. 
L. S. LippincQtt. 

LEON S. LIPPINCOTT, 

Secretary. 


METHOD OF CARRYING OUT TWO-STAGE OPERA- 
TIONS FOR CARCINOMA OF STOMACH.— Because of the 
troublesome experience with grastro-enterostomy it occurred 
to Donald C. Balfour, Rochester, Minn., that the difficulties 
might be avoided by dividing the stomach completely above 
the growth, closing the end of the lower segment and re- 
establishing gastro-intestinal continuity either by a retro- 
colic end-to-side gastrojfejunostomy or an antecolic end-to- 
side gastrojejunostomy with entero-anastomosis. The advan- 
tages of such a procedure are obvious. First, the operation 
can be done under local anesthesia; it takes but little more 
time than gastro-enterotomy. Second, perfect drainage of 
the stomach is established immediately, and the patient can 
take adequate nourishment without difficulty. Third, the 
second stage is usually simple, since the pyloric segment is 
free and can be mobilized quickly and easily. Furthermore, 
complete exclusion of the pyloric segment for a period of 
from ten to fourteen days will have lessened the activity of 
any inflammatory process to an astonishing degree, and 
growths which at the first operation appeared questionably 
removable nnfay now be resected with ease. Fnally, there 
is no interruption in the feeding of the patient, since there 


is nothing to be done with the upper segment of the stomach 
at the second stage. He gives a description of his method. 
— J. A. M. A., June 16, 1928. 


MECHANICAL TREATMENT OF EXPERIMENTAL 
RATTLESNAKE VENOM POISONING.— From the experi- 
mental reports made by Dudley Jackson ,San Antonio, Texas, 
and W. T. Harrison, Washington, D. C., it is quite evident 
that rattlesnake venom experimentally injected into dogs 
can readily be removed from the tissues by incision and 
suction, an animal receiving as high as four nrinimal lethal 
doses recovering when treatment has been delayed for one 
hour. This highly toxic material will escape in part from 
the edematous tissues if simple multiple punctures of the 
skin are made. That this fluid is highly toxic is shown by 
the fact that when injected in other dogs it will cause 
death with all the signs of venom poisoning. The poison 
contained in this fluid is neutralied in vitro by the specific 
antivenin and is not affected by diphtheria antitoxin: that 
the toxic fluid which is removed contains venom cannot 
therefore be questioned. — J. A. M, A., June 16, 1928. 


TRANSACTIONS OF ORLEANS PARISH MEDICAL SOCIETY 


Report of the Examinaticm of the Books of the Ordeans Parish Medical 
Society, New Orleans, for the Year Ending December 31st, 1927 

New Orleans, La., May 15th, 1928. 

Orleans Parish Medical Society, 

New Orleans, La. 

Gentlemen : 

In accordance with instructions received from your Treasurer, Dr. J. A. Lanford, 
I audited the books of the Society for the year ending December 31st, 1927, and sub- 
mit my report attached herewith. 

FINANCIAL CONDITION 

Domicile Fund 


Gold Bonds, see folio 12 

Savings Account, Marine Bank 

$31,374.96 

579.78 

$31,954.74 

General Fund 



Cash in bank : 

Petty Cash, in office 

Certificates of deposits 

Inventory of fixtures, see folio 6 

463.86 

16.20 

2,000.00 

658.12 

3,138.18 

Library Fund 



Cash in bank 

Petty Cash, in office 

Gold Bonds, see folio 12 

Inventory of books, see folio 7 

Inventory of fixtures, see folio 8 

178.04 

4.65 

7,878.98 

27,269.38 

2,155.45 

37,486.50 

Medical Relief Fund 


114.35 

Less insurance premiums paid in advance and due the 
• Insurance Co. to be paid at a later date 


72,693.77 

359.03 

Net Worth 


$72,334.74 


The $30,000.00 U. S. Liberty Bonds for account 
of the Domicile Fund held by the Society for 
some time were sold for $30, 510. 49 and various 
bonds bought for $30,380.96, see folio 11, leaving 
a credit balance of $135.53 which was placed in 
a savings account at the Marine Bank in the name 
of the Domicile Funds Savings Account, together 
with interest derived from the bonds. The inter- 
est derived from these bonds amount to $1,431.50 
and interest on the savings account amount to 
$6.75 making a total profit from this investment 
of $1,573.78. From this amount a Foster Creek 
Lumber and Manufacturing Co. bond was bought 
for $994.00, leaving a credit balance in the sav- 
ings account December 31st, 1927, of $579.78. A 
Gillican Chippley Co. bond was purchased for 
$1,005.67 for account of the Library Fund from 
cash obtained from the General Fund. A $500.00 
Missouri Pacific R. R. Co. bond held by the Soci- 
ety for sometime for account of the Library Fund 


was called at $537.50 and a Sea Board Air Line 
bond was purchased for $743.56. The amount 
paid for this bond was derived as follows: 

Proceeds of Mo. Pacific R. R. bond called $537.50 
Cash obtained from the General Fund.... 145.56 
Surplus carried over from 1926 from sale 

of a Mo. Pacific R. R. bond 60.50 

$743.56 

All cash receipts were fully verified and prop- 
erly recorded. The bonds of the Society are 
held by the Marine Bank & Trust Co. and the 
receipts for these bonds are in the bank box 
at the Marine Bank and were carefully checked 
by the writer and found correct and in accord 
with the records in the office. 

Respectfully submitted, 

L. L. JARREAU, 

Auditor. 


222 


Orleans Parish Medical Society 

ASSETS 


Domicile Fund 

Gold Bonds 

Savings Account 

General Fund 

Certificates of deposits, 3V2 % $2,000.00 

Cash in bank 463.86 

Petty Cash in office 16.20 

Office Fixtures Dec. 31/26 $564.63 

Discarded in 1927 3.50 

$561.13 

Acquired in 1927 96.99 658.12 

3,138.18 

Less Insurance Premiums paid in ad- 
vance 359.03 

Library Fund 

Cash in bank 

Petty cash in office 

Gold Bonds 

Inventory of fixtures Dec. 31/26 1,856.25 

Less discarded in 1927 4.00 

1,852.25 

Acquired in 1927 303.20 

Inventory of books 

Books on hand at Dec. 31/26 25,334.15 

Purchased in 1927 $180.27 

Binding in 1927 683.96 

* Subscriptions 100.00 

*Exchange 26.00 

♦Gifts 280.00 

*N. 0. Med. & Surg J1 665.00 1,935.23 


$31,374.96 

579.78 


31,954.74 


2,779.15 


178.04 

4.65 

7,878.98 


2,155.45 


27,269.38 


Medical Relief Fund 

Net Worth 

♦Estimated by Miss Marshall, Asst. Librarian. 


DOMICILE FUND 
Savings Account 

Difference betw^een the sale of the 
$30,000.00 Liberty Bonds and the 


cost -of bonds purchased $ 135.53 

Interest received 

Pontchartrain Apt. Bonds $ 260.00 
Gulfport Hotel Corp. Bond 180.00 
Fort Worth Property Bonds 325.00 

Grover Stewart Bonds 120.00 

Brown Paper Mills 180.00 

Hibernia Securities 90.00 

Gillican Chippley 30.00 

Nalle Buildings 120.00 

Marine Mortgage 150.00 


$1,455.00 

Less Commissions paid bank 23.50 $1,431.50 


$1,567.03 

Less purchase of the following' bond. 

Foster Creek Lumber & 

Manufacturing Co. Bond 994.00 


37,486.50 

114.35 


$72,334.74 


Interest on savings allowed 

by bank 6.75 


$579.78 

RECEIPTS, GENERAL FUND 

La. State Medical Society, Rent $ 240.00 

La. State Med. Society, Tel. & Tel 104.75 

Banquet Fund 630.00 

Dr. Davidson, Tel .15 

Trip to Washington, Miss Marshall re- 
funded by Library Fund 123.39 

Tulane Educational Fund, Chair sold.... 4.00 

Part of expense of graphophone rec- 
ords refunded 30.00 

Reminiscence sold 1.00 

Certificate of deposits redeemed 1,000.00 

Interest on Certificate of deposit re- 
deemed 13.72 

T. P. Talbot, Tel .87 

La. State Medical Soc. Dues 1,963.00 

Membership Dues 8,287.75 

N. 0. Medical & Surg. Jl. Tel 35.95 

Insurance Premiums 2,781.95 


$ 573.03 


$15,216.53 


Orleans Parish Medical Society 


223 


RECEIPTS, LIBRARY FUND 

2 Fire Extinguishers 


12.00 

Interest received on investments 


1 Brass Cuspidor 


1.50 

Gillican Chippley Bond.... 

$147.00 


5 Waste Baskets 


2.50 

Missouri Pacific R. R. Bond.... 

29.40 


1 Ballot Box 


1.50 

Sinclair Cons. Oil 


68.60 


1 Multigraph 


50.00 

3t. Chas. Ave. Baptist Church 

58.80 


1 Multigraph Stand 


4.00 

Holland American Bond. 


58.95 


1 Step Ladder 


1.50 

Baptist Convention of the State 



1 Awning 


12.65 

of Georgia 


58.80 


1 Hat Rack 


1.50 

Sea Board Air Line 


19.60 


1 Globe Fixture 


13.95 




$ 441.15 

1 Table Lamp 


11.50 

Other receipts 




1 Translux Screen 


90.85 

\^ppropriation from Gen’l Fund 

900.00 


1 Door Check 


1.00 

Missouri Pacific Bond called.. 

537.50 





From General Fund and 

ap- 





$561.13 

plied on purchase of 

Sea 



Acquired in 1927: 



Board Air Line Bond 


145.56 


1 Chair 

$19.50 




1,583.06 

1 Addressograph 

77.49 96.99 




$2,024.21 



$658.12 

General Fund 



INVENTORY OF 

BOOKS 


Cash on hand Dec. 31/26.. 



$ 1,214.56 

Library Fund 


Receipts 




Books on hand Dec. 31/26.--. 


$25,334.15 

Insurance Premiums 

$ 2,781.95 


Purchased in 1927 

$180.27 


Other receipts, see folio.... 

12,434.58 

15,216.53 

Binding in 1927 

683.96 






* Subscriptions, 1927 ....'. 

100.00 





$16,431.09 

* Exchange 

26.00 


Less Disbursements 



15,967.23 

* Gifts 

280.00 






*N. 0. Med. & Surg. Journal 

665.00 


Cash on hand Dec. 31/27.. 



463.86 



1,935.23 

Library Fund 







Cash on hand Dec. 31/26.. 

928.09 




$27,269.38 

Receipts 

2,024.21 


* Estimated by Miss Marshall, Asst. 

Librarian. 





INVENTORY OF FIXTURES 


2,952.30 


Librarv Fund 


jCss Disbursements 

2.774.26 









3 Wooden Tables 

9.00 


Cash on hand Dec. 31/27.. 



178.04 

9 Chairs 

9.00 






24 Rows Wood Shelves 

150.00 


Fotal cash on hand Dec. 




1 Ink Well 

.50 


31, 1927, both funds.... 



$ 641.90 

15 Rows Steel Shelves 

1,196.28 






1 Catalogue Case & Stand 

125.00 


INVENTORY OF FIXTURES 

1 Book Truck 

50.00 


General 

Fund 



1 Flat Top Desk 

30.00 


Steel Filing Cabinet 



$ 35.00 

1 Typewriter 

25.00 


Cardboard Cases 



3.00 

1 Steel Filing Cabinet 

35.00 


. Safe 



30.00 

Cardboard Boxes 

100.00 


1 Wooden Tables 



7.00 

Filing Boxes 

45.35 


Flat Desks 



..... 25.00 

Lights 

18.42 


Addressograph 



40.00 

1 Kardex Fili